For surgical residents presentation

1. SURGICAL SITE INFECTIONS
By
Dr. Olofin. K E

2. OUTLINE
• INTRODUCTION
• DEFINITION OF TERMINOLOGIES
• HISTORICAL PERSPECTIVE
• EPIDEMIOLOGY
• CLASSIFICATION
• PATHOGENESIS AND SURGICAL MICROBIOLOGY
• CLINICAL FEATURES
• FACTORS INFLUENCING SSI’s
• CLINICAL ASSESSMENT
• MANAGEMENT
• PREVENTION
• CONCLUSION

3. introduction
• A surgical site infection (SSI)refers to the
presence of pain at a surgically created
wound, which is accompanied by erythema,
induration and local tenderness or presence
of purulent discharge at wound site.
• They refer to infections of the tissues,
organs, or spaces exposed by surgeons
during performance of an invasive
procedure

4. definitions
• Colonization
– Bacteria present in a wound with no signs or
symptoms of systemic inflammation
– Usually less than 105 cfu/gram of tissue
• Contamination
– Transient exposure of a wound to bacteria
– Varying concentrations of bacteria possible
– Time of exposure suggested to be < 6 hours
– SSI prophylaxis best strategy

5. • Infection
–Systemic and local signs of inflammation
–Bacterial counts ≥ 105 cfu/gram of tissue
–Purulent versus nonpurulent
• Surgical wound infection is SSI

6. Definition of SSI’s
• Infection occurring
– anywhere along the surgical tract after a
surgical procedure
– anytime from 0 – 30 days post op.
OR
– up to 1 year post op. if a foreign material
was used(prosthesis).

7. Historical perspective
• Before the late 19th Century, serious
infections among hospitalized patients were
rampant and the morbidity & mortality
were astounding.
• Nearly all traumatic & surgical wound
healing was accompanied by inflammation
& suppuration.
• Galen; 130 – 200 AD “Suppuration often
heralded recovery”

8. • Theodoric of Cervia, Pare & Guy de Chuliac
disagreed with Galen’s dictum.
• 1861, Ignac Semmelweis; Washing of hands
→↓maternal mortality!
• 1867, Louis Pasteur showed that infection is
caused by microbes foreign to the infected.
• 1867, Joseph Lister introduced antisepsis

9. Epidemiology
• Incidence of SSI varies depending on the type
of surgical procedure carried out and the class
of surgical wound and maybe as high as 20%.
• SS-Infections are the 2nd most common
nosocomial infections.
• It also represents the commonest nosocomial
infection amongst surgical patients accounting
for 38% of NI’s.

10. Epidemiology
• Causes substantial morbidity and mortality
viz:
- post-op length of hospital stay by 7-10days
- Increases hospital charges substantially in
affected patients
- Death is directly linked to SSI in >75% of
patients with SSI who die in the post-op
period.

11. Classification
Classification of SSI’s could be based on
• Depth of Tissue involved
• Etiology
• Time
• Severity

12. classification
Surgical Site
infection
Incisional SSI
Superficial
Incisional SSI
Deep
Incisional SSI
Organ/space
SSI

13. Classification contd

14. Classification contd
• Etiology
a) Primary
The wound is the primary site of infection.
b)Secondary
Infection arises following a complication
that is not directly related to the wound.

15. Classification contd
• Time
a) Early
Infection presents within 30 days of
procedure
b) Intermediate
Occurs between 1-3 mths
c) Late
Presents >3mths post-surgery

16. Classification contd
• Severity
a) Minor
- Discharge without cellulitis/deep tissue
destruction
b) Major
- Pus discharge + tissue breakdown ,
- Partial or total dehiscence of the deep
fascial layers
- Presence of Systemic illness

18. Pathogenesis
Bacterial dose Virulence
Impaired
host resistance

19. Microbiology

20. Clinical features
• Erythema
• Discharge
–Superficial
–From drain(s)
• Pain
• Fever
• Tenderness
• Delayed return of bowel sounds
• Other inflammatory changes

23. FACTORS INFLUENCING DEVELOPMENT OF SSI’S
Patient factors
Multiple Co-Morbidities (Diabetes ,CKD,
P.VasDx)
Nicotine use
Immunosuppression (Steroid use, Malignancy)
Malnutrition (Obesity, Undernutrition)
Hospital stay 
Nares colonization with S. aureus
Transfusion.

24. • Pre-Op factors
• Preoperative antiseptic showering
• Preoperative hair removal
• Patient skin preparation in the operating room
• Preoperative hand/forearm antisepsis
• Antimicrobial prophylaxis

25. Pre-Op factors
 Preoperative hair
removal
  Shaving:
– immediately before the
operation: SSI rates 3.1%
– shaving within 24 hours
preoperatively: 7.1%
– having performed >24
hours: SSI rate > 20%.
 Hair removing creams:
– lower SSI risk than
shaving or clipping
– hypersensitivity
reactions
0
5
10
15
20
>24 Hr 24 Hr On table
SSI (%)

26. Prophylactic antibiotics
• Class 1 = Clean
• Class 2 = Clean contaminated (Prophylactic
antibiotics indicated)
• Class 3 = Contaminated(Prophylactic
antibiotics indicated)
• Class 4 = Dirty infected ( Therapeutic
antibiotics indicated)

27. ABX
Once the incision is made,
antibiotic delivery to the
wound is impaired.
Must give before incision!

29. Intra-Op factors
• Operating room environment
• Surgical attire and drapes
• Asepsis and surgical technique

30. Intra-Op factors
 Operating room environment
 Ventilation
- Positive pressure with respect to corridors and
adjacent areas.
 Environmental surfaces
- Rarely implicated as the sources of pathogens
important in the development of SSIs.
- Important to perform routine cleaning of these surfaces
 Conventional sterilization of surgical instruments
- Inadequate sterilization of surgical instruments has
resulted in SSI outbreaks

31. Intra-Op factors
 Surgical attire and drapes
 The use of barriers:
- patient: minimize exposure to the skin, mucous
membranes, or hair of surgical team members
- surgical team members: protect from exposure to
blood and blood-borne pathogens.
 Asepsis and surgical technique
 Rigorous adherence to the principles of asepsis by all scrubbed
personnel
 Excellent surgical technique: reduce the risk of SSI.
 Drains: increase incisional SSI risk.

32. Post-Op factors
• Incision care
Primary Closure, Delayed Primary Closure,
wound left open to heal by second intention.
• Haematoma/Seroma formation
• Foreign body
• Presence of non-viable tissue

33. Wound assessment
• The most common Surgical wound assessment
scores used include:
ASEPSIS SCORE
SOUTHAMPTON SCORE

34. ASEPSIS SCORE
• ADDitional Treatment
– Antibiotics
– Drainage under L.A.
– Debridement under G.A.
• Serous Discharge
• Erythema
• Purulent exudate
• Separation of wound
• Isolation of pathogen
• Stay in hospital > 2 weeks

35. ASEPSIS SCORE

36. Southampton Score

37. Management of SSI’s
• Source control
• Incision and Drainage
–Percutaneous
–Surgical
• Frequent wound dressing
• Débridement and delayed primary closure
• Antibiotic therapy.

38. Prevention
–Antisepsis
–Asepsis
–Antibiotics
–Manipulation of host factors to
minimize infection.

39. Pre-op precautions
• Pre op warming
• Cessation of smoking
• Adequate nutrition
• Plasma glucose control throughout
• Supplemental oxygen

40. Intra-op precautions
• Strict maintenance of asepsis
–Double gloving, strategic positioning
• Minimal handling of tissue
–Avoid desiccation, keep tissue warm...
–Ensure adequate tissue perfusion
–Ensure sufficient haemostasis

42. Intra-op precautions contd
• Avoid dead space
• Remove all necrotic/devitalized tissue
completely
• Justified drain use
• Delayed primary closure when indicated

43. Post-op Precautions
• Keep surgical incision(s) protected
• Continue effective antibiotic therapy
• Remove all drains as soon as practicable!
• Resume enteral nutrition as soon as
permissible
• Supplemental O2
• Keep patient warm

44. Conclusion

45. • THANKS FOR LISTENING!