SSI DEFINITIONS: PERIOD OF
SURVEILLANCE
 According to the National Center for Health Statistics, approximately 46
million surgical procedures are performed annually in the United States, the
majority of which are done in an outpatient setting.1
 Infection is the most common complication of surgery.2
 Surgical site infections (SSIs) occur in approximately 3% to 6% of
patients and prolong hospitalization by an average of 7 days at a direct
annual cost of $5 to $10 billion.3,4
 SSIs are the third (14%–16%) most frequent cause of nosocomial infections
among hospitalized patients.3
 Infection occurs within 30 days after the operative procedure if no implant is
left in place or within 1 year if implant is in place and the infection appears
to be related to the operative procedure
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SSI RISK FACTORS
 Age
 Obesity
 Diabetes
 Malnutrition
 Prolonged preoperative stay
 Infection at remote site
 Systemic steroid use
 Nicotine use
 Hair removal/Shaving
 Duration of surgery
 Surgical technique
 Presence of drains
 Inappropriate use of
antimicrobial prophylaxis
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04/18/17kaycee9901@outlook.com
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SSI incidence depends on both procedure- and patient-related
factors. Traditionally, the risk for SSIs has been stratified by surgical
procedure in a classification system developed by the National
Research Council (NRC; Table 127–1).5

PUBLIC HEALTH IMPORTANCE OF SURGICAL
SITE INFECTIONS
 In U.S., >40 million inpatient surgical procedures are performed
each year in an out patient settings ; 2-5% complicated by surgical
site infection
 SSIs second most common nosocomial infection (24% of all
nosocomial infections)
 Prolong hospital stay by 7.4 days
 Cost $400-$2,600 per infection (TOTAL: $130-$845 million/year)
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Cross Section of Abdominal Wall:
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FIGURE 127-1. Cross section of abdominal wall depicting Centers
for
Disease Control and Prevention classifications of surgical site infections
(SSI). (Reprinted from Am J Infect Control, Vol. 27, Mangram AJ, Horan
TC, Pearson ML, et al. Guideline for prevention of surgical site infection.
Copyright 1999, with permission from Elsevier. Centers for Disease
Control and Prevention (CDC) Hospital Infection Control Practices
Advisory Committee, Pages 97–132, Copyright 1999, with permission
from the Association for Professionals in Infection Control and
Epidemiology.)

SOURCE OF SSI PATHOGENS
 Endogenous flora of the patient
 Operating theater environment
 Hospital personnel (MDs/RNs/staff)
 Seeding of the operative site from distant focus of infection
(prosthetic device, implants)
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Microbiology of SSIs:
Staphylococcus
aureus
17%
Coagulase neg.
staphylococci
12%
Escherichia
coli
10%
Enterococcus
spp.
8%
Pseudomonas
aeruginosa
8%
Staphylococcus
aureus
20%
Coagulase neg.
staphylococci
14%
Escherichia
coli
8%
Enterococcus
spp.
12%
8%Pseudomonas
aeruginosa
1986-1989
(N=16,727)
1990-1996
(N=17,671)
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MICROBIOLOGY OF SSIS (CONTD) :
 Unusual pathogens
• Rhizopus oryzea - elastoplast adhesive bandage
• Clostridium perfringens - elastic bandages
• Rhodococcus bronchialis - colonized health care personnel
• Legionella dumoffii and pneumophila - tap water
• Pseudomonas multivorans - disinfectant solution
 Cluster of unusual SSI pathogens → formal epidemiologic investigation
 S. aureus is the most common pathogen causing SSIs, accounting for
30% of SSIs in the United States. Colonization with S. aureus, primarily
in the nares, occurs in roughly one in four persons and increases the
risk of SSI by 2- to 14-fold.146–152
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SSI RISK INDEX
 From the U.S. National Nosocomial Infections Surveillance (NNIS)
system
 American Society of Anesthesiologists (ASA) score
 1 to 5, from 1=“normal, healthy” to 5=“patient not expected to survive for 24
hours with OR without operation
 Wound Class
 Clean, clean-contaminated, contaminated, dirty
 Duration of surgery
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Rubour,(Redness)
Dolour, (pain, tenderness)
Tumour, (swelling)
DiagnosisDiagnosis
Fever
CRP, ESR, WBC
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PERIOPERATIVE PREVENTIVE
MEASURES
12

 It is important to recognize the difference between prophylactic and empiric
therapy.
 Prophylaxis is indicated for procedures associated with high infection rates,
those involving implantation of prosthetic material, and those in which the
consequences of infection are serious. The antibiotic should cover the most
likely contaminating organisms and be present in the tissues when the initial
incision is made. Therapeutic concentrations should be maintained throughout
the procedure.
 Empiric therapy is the continued use of antibiotics after the operative
procedure based upon the intra-operative findings. Empiric antibiotic therapy is
addressed in a separate guideline.
 Inappropriate prophylaxis is characterized by unnecessary use of broad-
spectrum agents and continuation of therapy beyond the recommended time
period. These practices increase the risk of adverse effects and promote the
emergence of resistant organisms.
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CHEMOPROPHYLAXIS:
 Antimicrobial prophylaxis is used to reduce the incidence of
postoperative wound infections. Patientsundergoing
procedures associated with high infection rates, those involving
implantation of prostheticmaterial, and those in which the
consequences of infection are serious should receive
perioperative antibiotics.
 Treatment, rather than prophylaxis, is indicated for procedures
associated with obvious preexisting infection (i.e. abscess, pus,
or necrotic tissue).
 The goal of prophylactic antibiotics is to reduce the incidence of
postoperative wound infection.
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ROLE OF ANTIMICROBIAL PROPHYLAXIS (AP)
IN PREVENTING SSI
 Refers to very brief course of an antimicrobial agent initiated just
before the operation begins
 Should be viewed as an adjunctive preventive measure
 Appropriately administered AP associated with a 5-fold decrease
in SSI rates
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RECOMMENDATIONS:
• Level I
􀂾 A single preoperative dose of antibiotic is as effective as a full 5-day course of therapy
assuming an uncomplicated procedure.
􀂾 Prophylactic antibiotics should be administered within 1 hour prior to incision.
􀂾 Complicated, contaminated, or dirty procedures should receive additional postoperative
coverage.
• Level II
􀂾 Prophylactic antibiotics should target the anticipated organisms.
􀂾 For the majority of procedures, prophylaxis should not exceed 24 hours.
􀂾 Prophylaxis is unnecessary if the patient is already receiving antibiotics that cover likely
pathogens.
􀂾 The timing of antibiotic administration should be adjusted to maximize prophylactic
efficacy.
􀂾 During prolonged procedures, antibiotic prophylaxis should be readministered every 3
hours
(with the exception of vancomycin, aminoglycosides, and fluroquinolones).
• Level III
􀂾 None
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LITERATURE REVIEW:
 Several studies have been performed investigating the utility of prophylactic
antibiotics in surgery. A wide variety of antibiotics, either singly or in combination,
have been evaluated. With regards to surgical prophylaxis, the data from these
studies support several recurring themes:
• A single preoperative dose of antibiotic is as effective as a 5-day course of
postoperative therapyassuming an
uncomplicated procedure (6, 7, 9-11)
• Prophylactic antibiotics should target the anticipated organisms (8, 9, 11).
• Complicated, contaminated, or dirty procedures should receive additional
postoperative coverage (12, 13, 14-19, 20).
• During prolonged procedures, antibiotic prophylaxis should be readministered
every 3 hours (1-5).
• Prophylactic antibiotics should be administered within 1 hour prior to incision (1-
7).
 The chart below summarizes the recommendations of several prospective,
randomized controlled studiesas well as several systematic literature reviews
addressing the use of prophylactic antibiotics in various surgical procedures (8-
20):
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EVALUATION OF THERAPEUTIC OUTCOMES:
-When evaluating the outcome of surgical antibiotic prophylaxis, it
is important to differentiate any potential SSI from other postoperative
infection or complication. Although fever and leukocytosis are
common in the immediate postoperative period, they typically
resolve with prompt ambulation, timely removal of invasive devices,
prevention and/or resolution of atelectasis through optimal respiratory
care, and effective analgesia. It is important to remember that
the emergence of distal infections, such as pneumonia, does not
constitute a failure of surgical prophylaxis. Prophylaxis should be as
short as possible because prolonged prophylactic regimens may
contribute to the selection of resistant organisms and may make any
infection more difficult to treat.
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NON PHARMACOLOGICAL
INTERVENTIONS
20

STERILIZED SURGICAL ATTIRE :
 Scrub suits
 Cap/hoods
 Shoe covers
 Masks
 Gloves
 Gowns
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PARAMETERS FOR OPERATING ROOM
VENTILATION*
 Temperature: 68o
-73o
F, depending on normal ambient temp [One
prospective trial of 200 patients undergoing colorectal surgery found that maintenance of
normothermia reduced postoperative infection rates along with other morbidity parameters,
including length of stay.21]
 Relative humidity: 30%-60%
 Air movement: from “clean to less clean” areas
 Air changes: >15 total per hour >3 outdoor air per hour
 Role of Laminar Air Flow (Ultraclean Air) in Preventing SSI
*American Institute of Architects, 1996
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ENHANCED PERIOPERATIVE GLUCOSE
CONTROL IN DIABETIC PATIENTS
 DESIGN: Prospective, sequential study
 POPULATION: Diabetic patients undergoing cardiac surgery
(N=2467) during 1987-1997
Controls: pts who received intermittent subQ insulin (SQI)
Treated: pts who received continuous intravenous (IV)insulin
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FURTHER DIRECTIONS :
 Additional research is needed in several areas related to surgical antimicrobial
prophylaxis. The risks and benefits of continuing antimicrobial prophylaxis after the
conclusion of the operative procedure, including dosing and duration, need to be
further evaluated. Insight is needed to make specific recommendations for
intraoperative repeat dosing, weight-based dosing in obese patients, and timing of
presurgical antimicrobials that must be administered over a prolonged period (e.g.,
vancomycin, fluoroquinolones). Additional clarification is needed regarding targeted
antimicrobial concentrations and intraoperative monitoring of antimicrobial serum
and tissue concentrations to optimize efficacy. The role of topical administration of
antimicrobial agents as a substitute for or an adjunct to i.v. antimicrobial prophylaxis
needs to be further evaluated. Additional data are needed to guide the selection of
antimicrobial agents for prophylaxis, particularly combination regimens, for patients
with allergies to b-lactam antimicrobials. Data are also needed to devise strategies to
optimize antimicrobial prophylaxis in patients and facilities with a high risk or high
prevalence of resistant organisms implicated in SSIs (e.g., MRSA). Optimal strategies for
screening for S. aureus and decolonization for certain procedures need to be identified.
Finally, outcomes studies are needed to assess the impact of using quality measures
and pay-for-performance incentives designed to reduce surgical morbidity and
mortality.
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REFERENCES :
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1. Antibiotic prophylaxis for surgery. Treatment guidelines. The Medical Letter 2004;2(20):27-32.
2. Antimicrobial prophylaxis in surgery. The Medical Letter 2001;43:92-98.
3. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. AJHP 1999;56:1839-1887.
4. Antimicrobial prophylaxis in surgery (clinical practice guidelines). Can Med Assoc J
1994;151(7):925- 931.
5. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the
national surgical infection prevention project. Am J Surg 2005;189:395-404.
6. Goodman J, Schaffner W, Collins H, et al. Infection after cardiovascular surgery. N Engl J Med.
1968; 278:117–23.
7. Perl TM. Prevention of Staphylococcus aureus infections among surgical patients: beyond traditional
perioperative prophylaxis. Surgery. 2003; 134:s10–7.
8. Kluytmans JA, Mouton JW, Ijzerman EP, et al. Nasal carriage of Staphylococcus aureus as a major
risk factor for wound infections after cardiac surgery. J Infect Dis. 1995; 171:2169.
9. Kluytmans JA, Mouton JW, Vanden-Bergh MF, et al. Reduction of surgical-site infections in
cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp
Epidemiol. 1996; 17:780–5.
10. Kalmeijer MD, Coertjens H, Van Nieuwland-Bollen PM, et al. Surgical site infections in orthopedic
surgery: the effect of mupirocin nasal ointment in a double-blind, randomized, placebo-controlled study.
Clin Infect Dis. 2002; 35:353–8.

REFERENCE [CONTD...]
o 11. Hacek DM, Robb WJ, Paule SM, et al. Staphylococcus aureus nasal decolonization in joint replacement
surgery reduces infection. Clin Orthop Relat Res. 2008; 466:1349–55.
o 12. White A, Smith J. Nasal reservoir as the source of extranasal staphylococci. Antimicrob Agents Chemother.
1963; 161:679–83.prophylaxis in high-risk gastroduodenal surgery. Can J Surg 1991; 34:177-222.
 13. Song F, Glenny AM. Antimicrobial prophylaxis in colorectal surgery: A systematic review of randomized
controlled trials. Br J Surg 1998; 85:1232-1241.
 14. Lewis RT, Goodall RG, Marien B, et al. Efficacy and distribution of single-dose preoperative antibiotic
prophylaxis in high-risk gastroduodenal surgery. Can J Surg 1991; 34:177-222.
 15. Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin. Obstet
Gyencol2006;108(1):225-234.
 16. Brown EM, deLouvois J, Bayston R, et al. Antimicrobial prophylaxis in neurosurgery and after head injury.
Lancet 1994; 344:1547-1551.
 17. Bayston R, de Louvois J, Brown EM, et al. Use of antibiotics in penetrating craniocerebral injuries. Lancet
2000; 355:1813-1817.
 18. Barker FG II. Efficacy of prophylactic antibiotics for craniotomy: A meta-analysis. Neurosurgery
1994;35:484-492.
 19. Barker FG II. Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery.
2002;51(2):391-400.
 20. Russell GV, King C, May CG, et.al. Once daily high-dose gentamicin to prevent infection in open fractures
of the tibial shaft: a preliminary investigation. South Med J 2001;94(12):1185-1191.
 21. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound
infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med
1996;334:1209–1215.
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YOU
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Surgical Site Infections Prophylaxis

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