Sirgical site infection

1. Surgical Site
Infection
Dr. Nazmul Azam
IMO, Dept of Surgery
TMC & RCH.

2. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

3. Introduction
 Surgical site infection is major problem in surgical practice.
 In 1992, the US centers for Disease Control (CDC) revised its
definition of ‘Wound infection’, creating the definition
‘Surgical site infection’ (SSI) to prevent confusion
between the infection of a surgical incision & the
infection of a traumatic wound.
 Accounts for 15-25% of all surgical infections & increased
cost o healthcare.

4. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

5. Definition
Surgical site infections (SSIs) are infections of the incision or organ
or space that occurs after surgery.
Within 30 days.
Within 1 years if FB implanted.
 Early infection : < 2 weeks.
 Delayed infection : 2-10 weeks.
 Late infection : > 10 weeks.

7. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

8. Types
Depth of wound
infection
Etiology
Time of
Occurrence
Severity

9. Depth – Superficial Incisional SSI
• Occurs < 30 days
• Skin & sub. Cut. Tissue
• Purulent Discharge +/-
• 1 sign of Inflamation.

11. Depth – Deep Incisional SSI
• Occurs – 30 days to 1 yrs
• Deep soft tissue
• Purulent dischargs- not from organ
• Spont. Opened or delibe.opened
• Deep abscess- by re-op/histo/Xray

13. Depth – Organ / Space SSI
• Occurs – 30 days to 1 yrs
• Involves – any part (organ/ space)
• Purulent discharge- Drain
• Organisms- isolated
• Deep abscess- by re-op/histo/Xray

15. Types of SSI
Etiology Time Severity
A. Primary :
Acquired from a
community or
endogenous source (such
as that following a
perforated peptic ulcer).
B. Secondary or
exogenous:
Acquired from the
OT (such as inadequate
air filtration) or ward
(e.g. poor hand washing
compliance) or from
after surgery (such as
anastomotic leak)
Early:
Infection occurs within
30 days of procedure
Intermediate:
Occurs between 1 to 3
months.
Late:
Occurs > 3 months after
surgery
Minor :
Wound infections may
discharge pus or infected
serous fluid but should not be
associated with excessive
discomfort, systemic signs of
delay in return home.
Major:
A major SSI is defined as
a wound that either
discharges significatnt
quantities of pus
spontaneously or needs a
secondary procedure to drain
it

16. Classification of Surgical Wounds

17. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

18. Micro-Organism
22%
17%
14%
9%
9%
5%
18%
4%
2%
S. aureus
S.epidermidis
Enterococcus
E. coli
Pseudomonas
Klebsiella
Gram -ve
Anaerobic
Gram +ve

19. Pathogenesis
Dose of bacterial contamination X virulence
Resistance of the host patient
Risk of SSI
Bacterial dose
Virulance
Impaired
Host resistance

20. Risk Factors
Patient Factors
 Age
 Obesity
 Smoking
 Malnutrition
 Immune compromised
 Prolong Pre-operative stay
 Remote site infection

21. Risk Factors
Procedure related
 Type of operation
 Duration of operation
 Skin shaving
 Skin preparation
 Peri operative hypoxia
 Theatre discipline
 Antibiotics prophylaxis
 Surgical technique
 Drain
 Wound hematoma

22. SSI_ Assessment
For surgical wound assessment several scoring systems are
employed
ASEPSIS Wound score
Southampton Wound grading system.

23. SSI_ Assessment

24. SSI_ Assessment

25. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
 Pre operative phase
 Intra operative phase
 Post operative phase
• How to look for SSI?
• How to treat SSI?

26. WHO adopted 29 recommendations
covering
23 topics for the prevention of SSI in the
preoperative, intraoperative, and postoperative
periods.

27. Pre operative Phase
 Pre operative Shower
• with soap or savlon.
• with in 8-12 hours.
 Shaving
 Patient Dress
 Theatre staff Dress
 Hand washing
 Antibiotic prophylaxis

28. Pre operative Phase
 Pre operative Shower
 Shaving
 No need.
 If needed:
• Limited to the area of surgery
• Day of surgery
 Disposable razor Vs Clipping/ Depilation
cream
 Patient Dress
 Theatre staff Dress
 Hand washing
 Antibiotic prophylaxis

29. Problems of Shaving
1. Pain
2. Allergy
3. Infection risk

30. Pre operative Phase
 Pre operative Shower
 Shaving
 Patient Dress
o Don’t interfere with operation site.
o Comfortable
o Maintain dignity
 Theatre staff Dress
 Hand washing
 Antibiotic prophylaxis

31. Pre operative Phase
 Pre operative Shower
 Shaving
 Patient Dress
 Theatre staff Dress
• Non sterile, Clean
• Cap & mask
• Shoes
• Goggles
 Hand washing
 Antibiotic prophylaxis

32. Pre operative Phase
 Pre operative Shower
 Shaving
 Patient Dress
 Theatre staff Dress
 Hand washing
 Betadine / Chlorhexidine
 No need for soap/ Brush
 5 minute ritual
 2 minute between cases/ hand scrub
 Antibiotic prophylaxis

33. Hand Wash in 5 min ritual

35. Pre operative Phase
 Pre operative Shower
 Shaving
 Patient Dress
 Theatre staff Dress
 Hand washing
 Antibiotic prophylaxis
 1 hour before incision :
 Before induction.
 Before tourniquet application.
 1 dose VS 3 dose :
 Additional dose:
o If prolonged operation.
o Excess blood loss.
 Drug : Bactericidal drug according to type of
surgery

36. Intra operative Phase
 Patient skin Preparation
• Iodine/ Chlorhexidine
• Allow to dry & avoid spillage to
diathermy pad.
 Incision drapes.
 Sterile Gown & gloves
 Patient Homeostasis
 Theatre discipline
 Wound dressing

37. Intra operative Phase
 Patient skin Preparation
 Incision drapes.
 No benefit
 Use iodopohor impregnated sticky draps
 Sterile Gown & gloves
 Patient Homeostasis
 Theatre discipline
 Wound dressing

38. Intra operative Phase
 Patient skin Preparation
 Incision drapes.
 Sterile Gown & gloves
 Water resistant gowns
 Double glove technique
 Patient Homeostasis
 Theatre discipline
 Wound dressing

39. Intra operative Phase
 Patient skin Preparation
 Incision drapes.
 Sterile Gown & gloves
 Patient Homeostasis
 Avoid Hypothermia :
 Warm fluids for infusion & for lavage
 Warm blankets & mattress
 Monitor temp. every 30 min interval
during surgery & post op.
 Avoid Hypoxia :
 Post operative mask O2 / SPO2
monitor
 Avoid hypotension:
 Infuse adequate fkuids
 Theatre discipline
 Wound dressing

40. Intra operative Phase
 Patient skin Preparation
 Incision drapes.
 Sterile Gown & gloves
 Patient Homeostasis
 Theatre discipline
• Sterile & Quiet environment
• Avoid to & fro movement
• Ensure sterility of equipments & Theatre
• Laminar airflow/ Filters
 Wound dressing

42. Intra operative Phase
 Patient skin Preparation
 Incision drapes.
 Sterile Gown & gloves
 Patient Homeostasis
 Theatre discipline
 Wound dressing
 Suture wound:
 Primapore / Tagaderm dressing with pad
 Open wound :
 Supratuli / Pad/ Crepe

43. Post operative Phase
 Post operative wound dressing
 Laparoscopy wounds : Remove after 24
hours.
 Laparotomy wounds : Remove 2 to 4 days
 Open wound dressing :
 Warm saline
 Non adherent dressing to maintain
moist environment.

44. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

45. Superficial Incisional Infection
Redness
Pain
Swelling
Heat
Discharging Pus

46. Deep Incisional Infection
Wound gaping
Fever
Pain
Discharge

47. Organ / Space SSI
Fever
Pain
Anorexia
Discharge through drain
Imaging study

48. Contents
• Introduction.
• What is SSI?
• Types of SSI.
• Risk factors of SSI.
• Prevention of SSI.
• How to look for SSI?
• How to treat SSI?

49. Treatment of SSI
 Surveillance.
 Drainage of pus
o Culture & sensitivity
 Debridment
 Antibiotics
 Removal of implant

50. Referances

51. Thank you