surgical site infections with current guidelines

2. Surgical Site Infection
BY:
DR Tariq RahimPGR surgery
DR M Ayyaz PGR Paeds

3. Definition
• Infection at the site of surgery that occurs within
30 days of surgery if there is no implant
(hardware artificial graft mesh etc)
• or within one year if implant is placed

4. INTERNATIONAL STATISTICS
• The frequency of SSI is dificult to moniter
becuase criteria for diagnose might not be
standarized,A survey sponsered by WHO
demonstrated a prevelence of nosocomal
infections in the range of 3-21% with SSI 5-34%
of total.

5. Defined by antomical locations
 Superficial Infections(47
%)(skin and
subcutaneaus tissues of
the incision)
 Deep incisional SSI(23%)
involved facia and
muscles layer
 OSI(30%)that involve any
part of anatomy other
yhen incison that was
open or manipulated

6. According to the time
Early with in 30 days
Intermediate 1-3 months
Late more than 3 months
According to Severity
Minor SSI :discharge without cellulites or deep tissue destruction
Major SSI :pus discharge with tissue breakdown, partial or total dehiscence or
systemic illness

7. • Human body has 1014
organisms which may
release into tissues before,during, and after
surgery.

8. SOURCE OF MICRORGANISMSSOURCE OF MICRORGANISMS
Endogenous microorganisms
Bacteria present on or in the patient at
the time of surgery
Most common source
S aureus most common isolate

9. Exogenous Microrganisms
outside patients
i.e OT( Inadequate air filteration,poor antiseptics)
ward(poor hand washing)

10. RISK FACTORS FOR SSI
PATIENT FACTORS
1. Older age
2. Immunosuppression
3. Obesity
4. Diabetes mellitus
5. Chronic
inflammatory
process
6. Malnutrition
7. Peripheral vascular
disease
8. Anemia
9. Radiation
10. Chronic skin disease
11. Carrier state (e.g.,
chronic Staphylococcus
carriage)

11. RISKS>>LOCAL FACTORS
. Poor skin preparation
2. Contamination of instruments
3. Inadequate antibiotic prophylaxis
4. Prolonged procedure
5. Local tissue necrosis
6. Hypoxia, hypothermia
1

12. RISK FACTORS cont..
Operative site shavingOperative site shaving
Breaks in operative sterileBreaks in operative sterile
techniquetechnique
Improper antimicrobialImproper antimicrobial
prophylaxisprophylaxis
Prolonged hypotensionProlonged hypotension
Contaminated operatingContaminated operating
roomroom
Poor wound carePoor wound care
postoperativelypostoperatively
HyperglycemiaHyperglycemia

13. National reserach counsil USA 1964
Wound Classification Risk of Infection with
prophylaxis and without
Clean 1-2% (1-2% without)
Clean-contaminated 3% (6-9% without)
Contaminated 6% (13-20% without)
Dirty and infected 7% (40 % without)

14. with out prosthetic clean
surgery No need of
prophylactic
antibiotics(Ref B&L)
if prosthetic implant then
needed
Abcess incision OR
contaminated wound
reqiure therapeutic
antibiotics lasting for 5-7
days

15. • Clean( no viscous opened)
• clean contiminated(viscus opened with MINIMAL
spillage)
• Contiminated(viscus opened with spillage and
inflammation)
• Dirty(perforating,incision through abcess)

16. PREVENTIONPREVENTION
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

17. Avoidance of Bacterial
Contamination:
a) Environmental factors
 Avoid exogenous and endogenous
contamination
 Use of ultraviolet light and laminar
flow
ventilation
 Limitation of traffic in and out of the
operating room
 Limitation of activity and talking
within the
operating room

18. • Preoperative preparation of the patient
 Preoperative showers with antiseptic agent at least
the night before (CHG soap)

19. Skin preparation
• Scrub the operative area for 5-7 mints.
• with germicidal solution and paint with pyodine
iodine or chlorhexidine.

20. Surgical Hand Antisepsis
• Surgical hand scrubs should:
 Significantly reduce microorganisms on intact skin
 Contain a non-irritating antimicrobial preparation
 Have broad-spectrum activity
 Be fast-acting and persistent

21. Surgical Hand Antisepsis
Perform pre op surgical scrub for atleast 2-5 mints
Scrub the hands and forearms upto the elbows
with appropriate antiseptic(dilute alchohol based
antiseptic hand soap or pyodine iodine.

22. Hair removel....
 Seropian & Reynolds study 406 clean
wounds showed that shaving increases
infection rate to 5.6% from 0.6% where
no shaving was done
Do not remove hair preoperatively unless it will
interfere with the operation.If hair removed,
remove just prior to surgery with electric
clippers.
Note,,,SSI after clean wound surgery Double if
shaving is performed a night before b/c minor
skin injury enhanced superficial colonization

23. Wear clean scrab suits, cap and mask
Careful wearing of gowns and gloves
Change puncture or tear gloves
Short preop stay decrease risk of MRSA
Staff with open infected skin lessions not
enter to OT
Decrease numbr of staff
movement IN?OUT should minimize
Regular survillence for instrument
sterilization

24. Study ResultsStudy Results
• Alchohol-CHG superior to PI in reducing the risk of SSI in clean-Alchohol-CHG superior to PI in reducing the risk of SSI in clean-
contaminated procedurescontaminated procedures
Darouiche RO, et al. New England Journal of Medicine 2010;362:18-26Darouiche RO, et al. New England Journal of Medicine 2010;362:18-26

25. Maintain NORMOTHERMIA
Patient become hypothermic B/c anesthesia/iV
fluids/anxiety/skin exposure
and hypothermia adversely effects
circulation/cougulations/wound healing/increase
infection...
So pre/intra Op warming by Ot temp..forced air
warming /warmed iv fluids

26. Antibiotic prophylaxis
• First let us know what is Decisive period.
• It is 4 hours interval B/W Trauma/surgery to
infection.
• Prophylactic antibiotics given in this period.
• Tissue level of antibiotics should high MIC90(minimum
inhibitoryconc)

27. • Antibiotics given at time of anesthesia
• A single Dose usually adequate but
• In long operation or excessive blood loss or
when unexpected contimination occure
antibiotics repeated 4hourly during surgery b/c
tissue antibiotics level fall faster then serum
level.

28. • After srgery Further dose of antibiotics....NO
VALUE in prophylaxis against infection (ref B&L)
• Ensure ABs at proper time/expected spectrum of
organisms/site and type of surgery / in correct
dose/and for recommended duration

29. Suggested Regimen ABs(prophylactic) and
suspected organisms)
vascular surgery
(stap aureus or MRSA,stap
epidermidis,aerobic gm -
bacilli)
orthopedic
(s aureus/s,epidermdis
oseophagiogastric
(E coli,enterococci)
one Dose of Augmintin
with or w/o gentacin
vancomycin or rifampicin
one dose of augmintin
one dose of 2 gen of
cephalosporin+metronida
zole

30. Billliary(E
coli/enterocooci)
small bowel
(E coli,Bacteriods)
Appendix/colorectal
(E coli,bacteriods)
one dose of 2 generation
cephalosporio
one dose of 2 generation
cephalosporin+
metronidazole
one dose of 2 generation
cephalosporin or
gentacin+metronidazole

31. Sterilization
• Sterilization of instruments began in 1880s,,
 Inadequate sterilization of surgical instruments has
resulted in SSI
 Surgical instruments can be sterilized by steam,
ethylene oxide, hydrogen peroxide plasma, vaporized
hydrogen peroxide, dry heat or other approved
methods
 Microbial monitoring of sterilization performance is
necessary and can be accomplished by biological
indicators

32. Post Op WOund Infection
• Severity of SSIs
• Two commonly used wound scoring system
• 1.ASEPSIS
• 2.Southampton wound assessment scale

33. • 1.ASEPSIS WOUND SCORING SYSTEM
• its quantitative scoring method that provide
numerical score related to the severity of wound
infection

34. Additional treatment
used of antibiotic
Drain of pus GA
Drain of pus LA
Serous discharge
Erythema
if yes 10 otherwise 0
==============
if yes 5 ow 0
0-5
0-5

35. less then 20% of wound
inloved
20-39%
40-59%
60-79%
greater then 80
1
2
3
4
5

36. purulant exudate
separation of deep tissue
0-10 points
0-10 points

37. less then 20% of wound
inloved
20-39%
40-59%
60-79%
greater then 80
2
4
6
8
10

38. isolation of bacteria from
wound
stay as in patient over 14
days
if yes 10 otherwise 0
===============

39. • score are given to each point and total points are
calculated and severity of wound infection
dtermined by total score and infection is
categorized as below

40. • total score 0-10(satisfactory wound healing)
• 11-20(disturbance of healing)
• 20-30(minor wound infection)
• 31-40(moderate wound infection)
• Greater then 40 (severe wound infection)

41. Southampton wound scoring system
• It is simpler then asepsis system with wound
being categorized according to complication and
there extent
• It grades from ..
• Grade 0..normal healing
• grade 1,,n h with mild bru and eryhe;;1a some
brusing,1b considrable brusing;1c erythema
• grade 2,,eryth +other signs of inflamtion

42. • 2a at one point.2b around suture,2c along
wound,2d around wound.
• grade 3...clear or haemoserous discharge..3a at
one point less then 2cm,,3b along wound
greater then 2cm,,3c large volume..3d prologed
greater then 3 days

43. • grade 4,,pus,,,4a at one point less then
2cm,,,,,4b along wound greater then 2cm
• grade 5 ,,,deep or severe wound infection with or
without breakdown,

44. Recognition and MX
of SSI
• SSI are identifeid by daily examine the wound
site..any erythema discharge or pus should be
noted
• systemic signs of infection along with
leukocytosis
• US and CT are usefull to identify amount and site
of collection

45. • when wound is under tension and there is clear
evidence of suppuration sutures should be
removed to drain the pus and wound should be
irrigated with saline solution and pus should be
send for c/s.
• Antibiotics should be initiated Empiricall initially
and wait for C/S report.
• Note..if empericall anti biotics is sensible
changes of ABs are unusual b/c

46. • of chances of resistance develop and cx like
pesdumem colitis
• if clinicall responce is poor antibiotics can be
change.

47. WHO Global Guidlines for prevention of
SSI
.patient with known nasal carriage of staph
aureus...
(by Dignostic swab)
So These patients must be decolonized pre op,,by
CHG bathing and intra nasal decolonization with
mupirocin 2%

48. WHO
)).. Oral antibiotics should use along with
MBP(mechanical bowel preparation) in elective
colorectal surgery,,
))..Hair should not removed or if absolutely
necesssary only removed with a cliipers (NO
SHAVING)

49. WHO
))Surgical antibiotic prophylaxis before surgical
incision when indicaed
))Surgeon hand scrubbing Antimicrobial soap/water
or alchohol based handrub
))surgical site scrubbing

50. WHO
• GA patients should ETT ,,80% fraction oxygen
intraoperatively and if feasible in the immediate
post op period for 2-6 hours
• SAP not prolonged after complition of operation

51. Conclusions
• Surgical site infections result in significant patient
morbidity and mortality, and increased hospital cost
• Reduction in surgical site infections can be achieved by
strict adherence to standard surgical guidelines
• Proper use of surgical prophylaxis crucial to maintaining
a low rate of SSIs

52. THANKS
SURGICAL B
FAMILY