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Surgical Site
Infection
Introduction
 Ignaz Semmelweis and Joseph Lister
became the pioneers of infection control
by introducing antiseptic surgery in middle
of 19th
century.
 Since then a number of significant
developments, particularly in the field of
microbiology, have made surgery safer
 In 1992, the US Centers for Disease
Control (CDC) revised its definition of
'wound infection', creating the definition
'surgical site infection' (SSI) to prevent
confusion between the infection of a
surgical incision and the infection of a
traumatic wound
Classification
 Incisional
 organ,
 or other organs and spaces manipulated
during an operation
Incisional infections are further classified
into-
 superficial (skin and subcutaneous tissue)
and
 deep (deep soft tissue-muscle and fascia)
Microbiology of Surgical Site
Infections
 In clean surgical procedures, in which the
gastrointestinal, gynecologic, and
respiratory tracts have not been entered,
Staphylococcus aureus from the
exogenous environment or the patient’s
skin flora is the usual cause of infection

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Surgical site infection

  • 2. Introduction  Ignaz Semmelweis and Joseph Lister became the pioneers of infection control by introducing antiseptic surgery in middle of 19th century.  Since then a number of significant developments, particularly in the field of microbiology, have made surgery safer
  • 3.  In 1992, the US Centers for Disease Control (CDC) revised its definition of 'wound infection', creating the definition 'surgical site infection' (SSI) to prevent confusion between the infection of a surgical incision and the infection of a traumatic wound
  • 4. Classification  Incisional  organ,  or other organs and spaces manipulated during an operation
  • 5. Incisional infections are further classified into-  superficial (skin and subcutaneous tissue) and  deep (deep soft tissue-muscle and fascia)
  • 6. Microbiology of Surgical Site Infections  In clean surgical procedures, in which the gastrointestinal, gynecologic, and respiratory tracts have not been entered, Staphylococcus aureus from the exogenous environment or the patient’s skin flora is the usual cause of infection
  • 7. Factors influencing SSIs (Lancet2000) Surgical considerations  Skin preparation  Site, duration and complexity of the surgery.  Presence of suture or foreign body  Suturing quality.  Pre-existing local or systemic infection  Prophylactic atibiotic  Haematoma  Mechanical stress on wound
  • 8. Anesthetic considerations  Tissue perfusion  Normovolaemia or hypovolaemia  Concentration of the inspired oxygen  Perioperative body temperature  Pain  Blood transfusion
  • 9. Patient related factors  Diabetes  Alcoholism  Smoking  Poor nutrition  Jaundice  Obesity  Advanced age  Poor physical condition
  • 10.  Surgical Factors- Decreased collagen synthesis  Anesthetic factors- Vasoconstriction  Patient factors -Immunosuppression
  • 11. Decreased tissue perfusion Decreased PtO2 Decreased collagen Decreased neutrophil Deposition Bactericidal activity Decreased wound Increased wound tensile strength Infection Wound break down
  • 12. Classification for operative wounds  Clean- Elective, not emergency, non- traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered.  Clean contaminated- Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy)
  • 13.  Contaminated- Non-purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma <4 hours old; chronic open wounds to be grafted or covered.  Dirty- Purulent inflammation (e.g. abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma >4 hours old. (Ann Surgery 1964)
  • 14. Rates of Infection  clean 2.1%,  clean-contaminated 3.3%,  contaminated 6.4% and  dirty 7.1% US National Nosocomial Infection Surveillance (NNIS) system
  • 15. Prevention of SSI  Appropriate use of antibiotics;  Appropriate hair removal;  Maintenance of postoperative glucose control  Maintenance of postoperative normothermia
  • 16. Antibiotics  One dose of antibiotic to be given preoperatively  It is generally recommended in elective clean surgical procedures and clean contaminated procedures that a single dose of cephalosporin to be administered intravenously
  • 17.  Involve pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration of antibiotic
  • 18. Hair removal  Hairs to be removed in OT just before surgery.  Use of clippers than razors reduces the chances of infection
  • 19. Glucose control  Implement a glucose control protocol.  Develop one protocol to be used for all surgical patients.  Regularly check preoperative blood glucose levels on all patients to identify hyperglycemia;  Assign responsibility and accountability for blood glucose monitoring and control.
  • 20. CDC surgical site infections prevention guidelines, 1999  Category 1A- Strongly recommended for implementation and supported by well- designed experimental, clinical, or epidemiologic studies  Treat remote infection before elective operation;  Postpone surgery until treated;
  • 21.  Do not remove hair from operative site unless necessary to facilitate surgery; If hair is removed, do immediately before surgery, preferably with electric clippers  Select an antimicrobial agent with efficacy against expected pathogen;  Intravenous route used to ascertain adequate serum levels during operation and for at most a few hours after incision closed
  • 22.  Category 1B- Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and strong theoretical rationale  Control serum blood glucose perioperatively;  Cessation of tobacco use 30 days before surgery;  Do not withhold necessary blood products to prevent SSIs
  • 23.  Shower or bath on night before operative procedure;  Wash incision site before performing antiseptic skin preparation with approved agent  Do not routinely use vancomycin for antimicrobial prophylaxis
  • 24.  Category II- Suggested for implementation and supported by suggestive clinical or epidemiologic studies or theoretical rationale  Prepare skin in concentric circles from incision site;  Keep preoperative stay in hospital as short as possible
  • 25. Superficial incisional surgical site infections  occur within 30 days of procedure  involve only the skin or subcutaneous tissue around the incision.
  • 26.  purulent drainage from the incision  organisms isolated from an aseptically obtained culture of fluid or tissue from the incision  at least one of the following signs or symptoms of infection - pain or tenderness, localised swelling, redness or heat - and the incision is deliberately opened by a surgeon, unless the culture is negative
  • 27. Don’t considered superficial SSIs  stitch abscesses  infection of an episiotomy or neonatal circumcision site  infected burn wounds  incisional SSIs that extend into the fascial and muscle layers
  • 28. Deep incisional surgical site infections  occur within 30 days of procedure (or one year in the case of implants)  are related to the procedure  involve deep soft tissues, such as the fascia and muscles.
  • 29.  purulent drainage from the incision but not from the organ/space of the surgical site  a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms - fever (>38°C), localised pain or tenderness - unless the culture is negative  an abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiological examination (CDC definitions of surgical wound infections )
  • 30. Wound assessment  ASEPSIS –to assess wounds resulting from cardiothoracic surgery  Southampton Wound Assessment Scale – categorized according to any complications and their extent
  • 33.  Score 0-10-satisfactory healing  11-20-disturbance of healing  20-30-minor wound infection  31-40-moderate wound infection  >41-severe wound infection
  • 34. Southampton scoring system Grade Appearance  0 Normal  I Normal healing with mild bruises and erythema  A Some bruising  B considerable brusing  C Mild erythema
  • 35. Grade Appearance  II Erythema plus other signs of infection  A At one point  B Around sutures  C Along wound  D Around wound
  • 36. Grade Appearance  III Clean or haemoserous discharge  A At one point only  B Along wound  C Large volume  D Prolonged
  • 37. Grade Appearance  IV Major wound complication like pus  A At one point only  B Along wound  V Deep or severe infection with or without breakdown
  • 38. Treatment  Surgical debridement of wound and antibiotics according to sensitivity