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DR. MANAL ELSAYED ABDELAZIZ
B.Sc.Pharm, CPHQ, DTQM, CLSSGB
TeamSTEPPS Master Trainer
• The third most common type of nosocomial
infection accounting for 14% to 16% of all
infections
• Among surgical patients, SSIs are the most
common nosocomial infection, observed in 38% of
cases.
• Two-thirds of these infections are due to the
incision, whereas one-third are due to infection of
the organs or spaces during surgery.
Surgical Site Infections
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
• Infections of the tissues, organs, or spaces
exposed by surgeons during performance of an
invasive procedure.
• Infections occurring up to 30 or 90 days after
surgery as per CDC definition 2015 and affecting
either the incision or deep tissue at the operation
site.
• Surgical sites are considered infected when there
are signs of systemic and local inflammation and
bacterial counts are 105 cfu/mL or higher.
Infections are also differentiated by purulence or
nonpurulence.
Surgical Site Infections
CDC Classification of SSI (Within 30 Days of
Operation, Within 1 Year if Implant in Place)
Surgical Site Infections
SSI
Mortality
Morbidity
LOS
Cost
• Patient flora (Skin, Mucous
membranes, GI tract)
• Seeding from a distant focus of
infection
Endogenous
• Surgical team (Soiled attire, Breaks in aseptic
technique, Inadequate hand hygiene)
• OR environment & ventilation
• Tools, equipment, materials in OR
Exogenous
Surgical Site Infections Pathogenesis
Surgical Site Infections Risk Factors
Surgical
Techniques
& Surgical
Drains
Skin
Antisepsis
& Body
Temp.
OR
Ventilation
Preoper-
ative
shaving
Inadequate
Instruments
Sterilization
Prophyla-
ctic
Antibiotic
Duration of
Surgery &
Surgical
Scrub
Operation
Factors
Age
Malnutrition
or Obesity
Diabetes
Preoperative
colonization
with Staph.
aureus
Nicotine or
Steroid Use
Prolonged
Preoperative
Stay
Altered
Immune
Response
Patient
Factors
Surgical Site Infections Risk Factors
• Lack of standardized methods for post-
discharge/outpatient surveillance with the
increased number of outpatient surgeries
• Increasing trend toward resistant
organisms may undermine the
effectiveness of existing
recommendations for antimicrobial
prophylaxis
Surgical Site Infections Challenges
Core Strategies
High levels of scientific evidence
Demonstrated feasibility
Supplemental
Strategies
Some scientific evidence
Variable levels of feasibility
Surgical Site Infections
Prevention Strategies
Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not
included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC
guidelines may be found at www.cdc.gov/hicpac
Administer antimicrobial prophylaxis in
accordance with evidence based standards and
guidelines
• Administer within 1 hour prior to incision*
• 2hr for vancomycin and fluoroquinolones
• Select appropriate agents on basis of
• Surgical procedure
• Most common SSI pathogens for the procedure
• Published recommendations
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures.
Surg Infect 2008;9(6):579-84.
Surgical Site Infections
Prevention Strategies: Core
Preoperative Measures
Remote infections-whenever possible:
• Identify and treat before elective operation
• Postpone operation until infection has resolved
Do not remove hair at the operative site unless it
will interfere with the operation; do not use
razors
• If necessary, remove by clipping or by use of a
depilatory agent
Surgical Site Infections
Prevention Strategies: Core
Preoperative Measures
Skin Prep
• Use appropriate antiseptic agent and technique for skin
preparation
Maintain immediate postoperative normothermia*
Colorectal surgery patients
• Mechanically prepare the colon (Enemas, cathartic
agents)
• Administer non-absorbable oral antimicrobial agents in
divided doses on the day before the operation
Surgical Site Infections
Prevention Strategies: Core
Preoperative Measures
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National
Quality Measures. Surg Infect 2008;9(6):579-84.
Operating Room (OR) Traffic
• Keep OR doors closed during surgery except as
needed for passage of equipment, personnel, and the
patient
Surgical Site Infections
Prevention Strategies: Core
Intraoperative Measures
Surgical Site Infections
Prevention Strategies: Core
Postoperative Measures
Surgical Wound Dressing
• Protect primary closure incisions with sterile dressing for 24-48
hrs post-op
Control blood glucose level during the immediate post-
operative period (cardiac)*
• Measure blood glucose level at 6AM on POD#1 and #2 with
procedure day = POD#0
• Maintain post-op blood glucose level at <200mg/dL
Discontinue antibiotics within 24hrs after surgery end
time (48hrs for cardiac)*
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National
Quality Measures. Surg Infect 2008;9(6):579-84.
Nasal screen and decolonize only
Staphylococcus aureus carriers undergoing
elective cardiac and other procedures (i.e.,
orthopaedic, neurosurgery procedures with
implants) with preoperative mupirocin therapy*
Bode LGM, etal. Preventing SSI in nasal carriers of Staph aureus. NEJM 2010;362:9-17
Screen preoperative blood glucose levels and
maintain tight glucose control POD#1 and POD#2
in patients undergoing select elective
procedures (e.g., arthroplasties, spinal fusions)*
Surgical Site Infections
Prevention Strategies:
Supplemental Preoperative
Measures
NOTE: These supplemental strategies are not part of the 1999 HICPAC Guideline for Prevention of Surgical Site Infections
Surgical Site Infections
Prevention Strategies:
Supplemental Perioperative
Measures
Re-dose antibiotic at the 3 hr interval in procedures
with duration >3hrs *
See exceptions to this recommendation in Engelman R, et al. The Society of Thoracic Surgeons Practice Guideline Series:Antibiotic
Prophylaxis in Cardica Surgery, Part II:Antibiotic Choice. Ann Thor Surg 2007;83:1569-76
Adjust antimicrobial prophylaxis dose for obese
patients (body mass index >30)*
Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol
2008;29 (Suppl 1):S51-S61
Use at least 50% fraction of inspired oxygen
intraoperatively and immediately postoperatively in
select procedure(s)*
Maragakis LL, Cosgrove SE, Martinez EA, et al. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site
infection after spinal surgery. Anesthesiology 2009;110:556-562. and
Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary
complications after abdominal surgery: The PROXI randomized clinical trial. JAMA 2009;302:1543-1550.
Feedback of surgeon specific infection rates.
Surgical Site Infections
Prevention Strategies:
Supplemental Postoperative
Measures
Surgical Site Infections (SSI)
Surgical Site Infections (SSI)

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Surgical Site Infections (SSI)

  • 1. DR. MANAL ELSAYED ABDELAZIZ B.Sc.Pharm, CPHQ, DTQM, CLSSGB TeamSTEPPS Master Trainer
  • 2. • The third most common type of nosocomial infection accounting for 14% to 16% of all infections • Among surgical patients, SSIs are the most common nosocomial infection, observed in 38% of cases. • Two-thirds of these infections are due to the incision, whereas one-third are due to infection of the organs or spaces during surgery. Surgical Site Infections Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
  • 3. • Infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure. • Infections occurring up to 30 or 90 days after surgery as per CDC definition 2015 and affecting either the incision or deep tissue at the operation site. • Surgical sites are considered infected when there are signs of systemic and local inflammation and bacterial counts are 105 cfu/mL or higher. Infections are also differentiated by purulence or nonpurulence. Surgical Site Infections
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  • 8. CDC Classification of SSI (Within 30 Days of Operation, Within 1 Year if Implant in Place) Surgical Site Infections SSI Mortality Morbidity LOS Cost
  • 9. • Patient flora (Skin, Mucous membranes, GI tract) • Seeding from a distant focus of infection Endogenous • Surgical team (Soiled attire, Breaks in aseptic technique, Inadequate hand hygiene) • OR environment & ventilation • Tools, equipment, materials in OR Exogenous Surgical Site Infections Pathogenesis
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  • 11. Surgical Site Infections Risk Factors Surgical Techniques & Surgical Drains Skin Antisepsis & Body Temp. OR Ventilation Preoper- ative shaving Inadequate Instruments Sterilization Prophyla- ctic Antibiotic Duration of Surgery & Surgical Scrub Operation Factors
  • 12. Age Malnutrition or Obesity Diabetes Preoperative colonization with Staph. aureus Nicotine or Steroid Use Prolonged Preoperative Stay Altered Immune Response Patient Factors Surgical Site Infections Risk Factors
  • 13. • Lack of standardized methods for post- discharge/outpatient surveillance with the increased number of outpatient surgeries • Increasing trend toward resistant organisms may undermine the effectiveness of existing recommendations for antimicrobial prophylaxis Surgical Site Infections Challenges
  • 14. Core Strategies High levels of scientific evidence Demonstrated feasibility Supplemental Strategies Some scientific evidence Variable levels of feasibility Surgical Site Infections Prevention Strategies Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*) after the strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac
  • 15. Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines • Administer within 1 hour prior to incision* • 2hr for vancomycin and fluoroquinolones • Select appropriate agents on basis of • Surgical procedure • Most common SSI pathogens for the procedure • Published recommendations *Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84. Surgical Site Infections Prevention Strategies: Core Preoperative Measures
  • 16. Remote infections-whenever possible: • Identify and treat before elective operation • Postpone operation until infection has resolved Do not remove hair at the operative site unless it will interfere with the operation; do not use razors • If necessary, remove by clipping or by use of a depilatory agent Surgical Site Infections Prevention Strategies: Core Preoperative Measures
  • 17. Skin Prep • Use appropriate antiseptic agent and technique for skin preparation Maintain immediate postoperative normothermia* Colorectal surgery patients • Mechanically prepare the colon (Enemas, cathartic agents) • Administer non-absorbable oral antimicrobial agents in divided doses on the day before the operation Surgical Site Infections Prevention Strategies: Core Preoperative Measures *Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.
  • 18. Operating Room (OR) Traffic • Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient Surgical Site Infections Prevention Strategies: Core Intraoperative Measures
  • 19. Surgical Site Infections Prevention Strategies: Core Postoperative Measures Surgical Wound Dressing • Protect primary closure incisions with sterile dressing for 24-48 hrs post-op Control blood glucose level during the immediate post- operative period (cardiac)* • Measure blood glucose level at 6AM on POD#1 and #2 with procedure day = POD#0 • Maintain post-op blood glucose level at <200mg/dL Discontinue antibiotics within 24hrs after surgery end time (48hrs for cardiac)* *Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.
  • 20. Nasal screen and decolonize only Staphylococcus aureus carriers undergoing elective cardiac and other procedures (i.e., orthopaedic, neurosurgery procedures with implants) with preoperative mupirocin therapy* Bode LGM, etal. Preventing SSI in nasal carriers of Staph aureus. NEJM 2010;362:9-17 Screen preoperative blood glucose levels and maintain tight glucose control POD#1 and POD#2 in patients undergoing select elective procedures (e.g., arthroplasties, spinal fusions)* Surgical Site Infections Prevention Strategies: Supplemental Preoperative Measures NOTE: These supplemental strategies are not part of the 1999 HICPAC Guideline for Prevention of Surgical Site Infections
  • 21. Surgical Site Infections Prevention Strategies: Supplemental Perioperative Measures Re-dose antibiotic at the 3 hr interval in procedures with duration >3hrs * See exceptions to this recommendation in Engelman R, et al. The Society of Thoracic Surgeons Practice Guideline Series:Antibiotic Prophylaxis in Cardica Surgery, Part II:Antibiotic Choice. Ann Thor Surg 2007;83:1569-76 Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30)* Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29 (Suppl 1):S51-S61 Use at least 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s)* Maragakis LL, Cosgrove SE, Martinez EA, et al. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology 2009;110:556-562. and Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: The PROXI randomized clinical trial. JAMA 2009;302:1543-1550.
  • 22. Feedback of surgeon specific infection rates. Surgical Site Infections Prevention Strategies: Supplemental Postoperative Measures