2. WHY THIS TOPIC?
SSI is MOST COMMON hospital acquired infection in
surgical patients.
3rd most common hospital acquired infection.
Preventable
Prolong the hospital stay (7.3
days) Expenditure
Over one-third of postoperative deaths
Poor scar, persistent pain and itching, restriction of movement
an
d
5. ALEXANDER FLEMING
5
• The discovery of the antibiotic penicillin is
attributed to Alexander Fleming in 1928, but it
was not isolated for clinical use until 1941 by
Florey and Chain.
• Since then, there has been a proliferation of
antibiotics with broad-spectrum activity and
antibiotics today remain the mainstay of
antimicrobial therapy.
Ref: Bailey & Love’s Short Practice of Surgery, 27th Edition.
6. WHAT IS SSI?
Surgical site infections
(SSIs) are infections of
the tissues, organs, or
spaces exposed by
surgeons during
performance of an
invasive procedure.
9. SUPERFICIAL INCISIONAL
SURGICAL SITE
INFECTIONS
Infection occurs within 30 days of procedure
Involve skin or subcutaneous tissue
At least one of the followings:
• purulent drainage +/-
• organisms isolated aseptically from fluid or tissue of superficial incision
• Superficial incision that is deliberately opened by the surgeon & is culture positive
or not cultured
• Patient has one of the followings signs/symptoms(pain/tenderness,localised
swelling,redness,temparature
11. DEEP INCISIONAL SURGICAL SITE
INFECTIONS
• Infection occur within 30 days of procedure (or one
year in the case of implants)
• Involve deep soft tissues, such as the fascia and
muscles.
At least one of the followings:
• purulent drainage from deep incision, signs of infection
• spontaneously dehisces or opened by surgeon & is culture
positive or not cultured
• Fever >38 degree c,localized pain or tenderness
• an abscess or other evidence of infection found on direct
exam,during invasive procedure,by HPE,by imaging test
• Diagnosis of deep ssi by surgeon or attending physician
13. ORGAN OR SPACE SURGICAL SITE
INFECTION
30 days no implant or 1 year with implant
Any part is involved which was opened or manipulated
other than the incision
At least one of the followings:
• purulent drainage from deep incision, signs of infection
• Organism isolated from an aseptically obtained culture of fluid
or tissue in the organ/space
• an abscess or other evidence of infection found on direct
exam,during invasive procedure,by HPE,by imaging test
• Diagnosis of deep ssi by surgeon or attending physician
15. Earl
y
• Infection
presents
within 30
days of
procedure
Intermediat
e
• Occurs
between
one and
three
months
Lat
e
• Presents
more than
three
months after
surgery
According
to time
16. According to
MINOR
• Wound infection is
described as minor
when there is
discharge without
cellulitis or deep
tissue destruction
MAJO
R
• When there is pus
discharge with tissue
breakdown , Partial
or total dehiscence
of the deep fascial
layers of wound or if
systemic illness is
present.
17. The risk is also
microorganism
related to the amount of contamination with
s which is called “class” of the operation
Surgical wounds
classification
DEFINITION
• Ref:CDC
Clea
n
Operations in which no inflammation is encountered and the
respiratory, alimentary or genitourinary tracts are not entered.
There is no break in aseptic operating theatre
technique.eg:hernioplasty,thyroidectomy,surgeries of
brain,joints,heart & transplant.
Clean-
contaminated
Operations in which the respiratory, alimentary or genitourinary
tracts are entered but without significant
spillage.Eg:appendectomy,GJ,pancratic & biliary surgery
Contaminate
d
Operations where acute inflammation (without pus) is
encountered, or where there is visible contamination of the
wound. Examples include gross spillage from a hollow viscus
during the operation or compound/open injuries operated on
within four hours
Dirty
Operations in the presence of pus, where there is a previously
perforated hollow viscus, or compound/open injuries more than
four hours old.Eg:Abscess,perforated viscous with peritonitis,fecal
contamination
21. SEPSIS 3.0
• Ref: INTERNATIONAL GUIDELINES FOR MANAGEMENT
OF SEPSIS & SEPTIC SHOCK,2016
SEPSIS 2(OLD)
22. PATHOGENESIS OF SURGICAL SITE
INFECTION
Contamina
ti
on
• Endogeno
us
infection
• Exogeno
us
infection
• Haematogen
o us spread
• Staph
aureu
s
• Enterobact
e riaceae
and
anaerobes
Proliferatio
n
of bacteria
Induce
inflammatio
n
– signs
appear
Identified
or
unidentifie
d
Self
resolving
-> resolve
by
treatment -
> sepsis
and death
25. Local factors
• Poor skin preparation
• Contamination of instruments
• Inadequate antibiotic
prophylaxis
• Prolonged procedure
• Site and complexity of
procedure
• Local tissue necrosis
• Hypoxia
29. PRE OPERATIVE
PHASE
• Pre op Shower
– With
soap(CHLORHEXI
DINE SOAP)
– Day before or on
thev day of
surgery(8-12 hrs
prior)
• Nasal
decontamination:
Consider nasal
mupirocin
Ref:NICE Guideline on Prevention and treatment of surgical site infection,
(National
30. PRE OPERATIVE
PHASE
• Shaving:
• Limited to the area of surgery
• Day of surgery
– Disposable razor
– Depilation cream
– Electric clippers with single use Clipping
Ref:NICE Guideline on
Prevention and treatment of
surgical site infection,
(National
Institute for Health and
Clinical Excellence, 2018-
31. PRE-OPERATIVE
SHAVING/HAIR REMOVAL
Method of hair
removal Razor =
5.6% SSIrates
Depilatory = 0.6% SSI rates
Timing of hair removal
Shaving immediately
before Shaving 24
hours before Shaving
>24 hours before
= 3.1% SSI
rates
= 7.1% SSI
rates
= 20% SSI 29
Ref:CDC
33. PRE OPERATIVE PHASE
Patient theatre wear:
Give patients specific theatre wear that is appropriate for the
procedure and clinical setting, and that provides easy access
to the operative site and areas for placing devices, such as
intravenous cannulas. Take into account the patient's
comfort and dignity
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
34. PRE OPERATIVE
PHASE
• Theatre staff’S
Dress
– Non-Sterile&
clean
• Cap & Mask
• Shoes
• Goggles
• Staff leaving the
operating area:
minimum movements
in & out of the
operating area
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
35. PRE OPERATIVE
PHASE
• Mechanical bowel
preparation:
– Do not use mechanical
bowel preparation to
reduce ssi
• Hand jewellery, artificial
nails & polish
The operating team
should remove hand
jewellery or artificial
nails or polish
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
36. PRE OPERATIVE
PHASE
• Hand washing
– Betadine/Chlorhexidi
ne
– No need for
soap/brush
– 5 minute ritual
– 2 minute between
cases/hand scrub
37. PRE OPERATIVE
PHASE
• Antibiotic prophylaxis
– 1 hour before incision
• Before incision!
• Additional dose:
–if prolonged operation
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
38. ANTIBIOTIC PROPHYLAXIS
• Give antibiotic prophylaxis to patients before:
– clean surgery involving the placement of a prosthesis or
implant
– clean-contaminated surgery
– contaminated surgery.
• Do not use antibiotic prophylaxis routinely for clean
non- prosthetic uncomplicated surgery.
• Use the local antibiotic formulary and always consider
potential adverse effects when choosing specific
antibiotics for prophylaxis.
• Consider giving a single dose of antibiotic
prophylaxis intravenously on starting
anaesthesia.
• For operations in which a tourniquet is used
give prophylaxis earlier
Ref:NICE Guideline on Prevention and treatment of surgical site infection,
36
40. IMPORTANCE OF TIMING OF
SURGICAL ANTIMICROBIAL
PROPHYLAXIS (AP)
• Prospective study of 2,847 elective clean
and clean-contaminated procedures
• Early AP (2-24 hrs before
incision):
• Postop AP (3-24 hrs after
incision):
• Periop AP (< 3 hrs after
3.8
%
3.3
%
1.4
Ref:CDC
41. INTRA OPERATIVE
PHASE
• Sterile Gown &
Gloves
– Water resistant gowns
– Double glove
technique
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
42. INTRA OPERATIVE
PHASE
• Patient skin
Preparation
– Iodine/Chlorhexidine
– Allow it to dry & avoid
spillage to diathermy pad
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
43. INTRA OPERATIVE
PHASE
• Incision drapes
– Use iodophor impregnated sticky
drapes unless the patient has an
iodine allergy
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
44. INTRA OPERATIVE
PHASE
• Diathermy
– Don’t use diathermy for surgical
incision to reduce SSI
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
45. INTRA OPERATIVE
PHASE
• Patient Homeostasis
– Avoid Hypothermia
• Warm fluids for infusion and for lavage
• Warm blankets
• Warm mattress
• Monitor temperature every 30 min during surgery and post
op
– Avoid Hypoxia
• Post operative mask O2 / monitor Spo2
– Avoid hypotension
• Infuse adequate fluids
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
46. INTRA OPERATIVE
PHASE
• Theatre discipline
– Sterile & Quiet environment
– Avoid to & fro movement
– Ensure sterility of equipments &
Theatre
– Laminar airflow/Filters
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
47. PARAMETERS FOR OPERATING ROOM
VENTILATION
• Temperature:68o-73oF, depending on
normal ambient temp
30%-60%
from “clean to less
clean”
• Relative
humidity:
• Air
movement:
areas
• Air changes:
>15 total per hour
>3 outdoor air per
hour
Ref:American Institute of Architects
49. INTRA OPERATIVE PHASE
• Wound irrigation &
intracavitary lavage:
Don’t give to reduce ssi
• Antiseptics & antibiotics
before wound closure:
Under clinical research trial
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
50. INTRA OPERATIVE PHASE
• Wounds closure methods:
Consider using sutures
rather than staplers to
reduce the superficial
wound dehiscence
Consider using triclosan-
coated suture especially in
pediatric surgery to reduce
ssi
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
51. INTRA OPERATIVE PHASE
• Wound dressing:
Cover surgical incisions with
appropriate interactive
dressings at the end of
operation
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
52. POST-OPERATIVEMEASURES
52
• Changing dressings
– Use an aseptic non-touch technique for
changing or removing surgical wound
dressings.
• Postoperative cleansing
– Use sterile saline for wound cleansing up to 48 hours
after
surgery.
– Advise patients that they may shower safely 48 hours
after surgery.
– Use tap water for wound cleansing after 48 hrs if the
surgical wound has separated or has been opened
surgically to drain pus
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
53. POST-OPERATIVEMEASURES
53
• DON’T use Topical antimicrobial agents for
wound healing by primary intention
• Dressings for wound healing by
secondary intention
– Do not use Eusol and gauze, or moist cotton
gauze or mercuric antiseptic solutions.
– Use an appropriate interactive dressing.
Ref:NICE Guideline on Prevention and treatment of surgical site
infection, (National
Institute for Health and Clinical Excellence, 2018-19.)
54. POST-OPERATIVE MEASURES
• Antibiotic treatment of surgical site
infection and treatment failure
– When surgical site infection is suspected (i.e.
cellulitis), either de novo or because of
treatment failure,
– give the patient an empirical antibiotic that
covers the likely causative organisms.
• Debridement:
Don’t use eusol/gauze or enzymatic
treatments for debridement to
reduce ssi
Ref:NICE Guideline on Prevention and treatment of surgical site infection,
(National
55.
56. MANAGEMENT OF SSI
• Surveillance
• Drainage of pus
– Culture and
sensitivity
• MRSA
• VRE
• ESBL strains
• Debridement
• Antibiotics
• Removal of Implant
58. MANAGEMENT OF INCISIONAL SURGICAL SITE
INFECTION
• Removal of sutures with drainage of pus
• Pus sent for c/s
• Debridement and open wound care
• Delayed primary or secondary suture
once wound shows signs of healing by
healthy granulation tissue
59. TAKE HOME MESSAGE
TYPES OF SSI
SEPSIS 3.O
NICE GUIDELINES FOR PREVENTION OF
SSI
MEASURES TAKEN
ANTIBIOTIC PROPHYLAXIS
MANAGEMENT OF SSI
61. References:
• Bailey & Love’s Short Practice of Surgery, 27th Edition
• Sabiston Textbook of Surgery
• NICE guidelines of SSI
• WHO guidelines of SSI
• SRB manual of Surgery,6th ed
