ssi

1. Surgical Site Infections

2. Nosocomial Pathogens
NNIS, Jan. 1990 - Mar. 1996
0
5000
10000
15000
20000
25000
30000
35000
40000
Urinary Tract
Infection
Surgical Site
Infection
Bloodstream
Infection
Pneumonia Other Sites
Number
of
Isolates

3. DEFINITION

4. EPIDEMIOLOGY
wound classification
 I. Clean
 II. Clean contaminated
 III. Contaminated
 IV. Dirty procedures

5. Risk Factors for SSI: The
Patient
 Age
 Nutritional status
 Diabetes
 Nicotine use
 Obesity
 Coexistent infection
 Colonization
 Altered immune response
 Long preoperative stay
How effectively can we control these risk factors?

6. Risk Factors for SSI: Pre- and
Intraoperative
 Inappropriate use of antimicrobial prophylaxis
 Infection at remote site not treated prior to surgery
 Shaving the site vs. clipping
 Long duration of surgery
 Improper skin preparation
 Improper surgical team hand antisepsis
 Environment of the room (ventilation, sterilization)
 Surgical attire and drapes
 Surgical technique: hemostasis, sterile field
To a great extent, this is what we can
control!

7. ASA
PHYSICAL STATUS
SCORE
ASA1
ASA 2
ASA 3
ASA 4
ASA 5

8. Microbiology
S. aureus
S. epidermidis
Enterococcus
E. coli
Pseudomonas
klebsiella
Gr -ve
strept species
anaerobic
Gr +ve
19%
14%
12%
12%
8%
8%
4%
15%
6% 3%2%

9. HICPAC - SSI Prevention
Guidelines - 1999
No prior infections 15 air changes/hr in O.R.
Do not shave in advance Keep O.R. doors closed
Control glucose in patients with DM Use sterile instruments
Stop tobacco use Wear a mask
Shower with antiseptic soap Cover hair
Prep skin with approp. agent Wear sterile gloves
Surgeon’s nails short Gentle tissue handling
Surgeons scrub hands DPC for heavily contaminated
Exclude infected surgeons wounds
Give prophylactic antibiotics Closed suction drains
Pos pressure ventilation in O.R. Sterile dressing x 24-48 hr

10. Preoperative preparation
The pt should be assessed for factors that can be corrected in the
preoperative period before elective surgery. Open skin lesions should be
allowed to heal if possible,
Pt should be free of any bacterial infection of any kind
Should quit smoking if possible preferably one month before operation
Particular attention should be paid on the nutritional status of the pt obese pt
should loose wt as much as possible malnourished pt can benefit from even
brief courses of enteral nutritional supplement as little as 5 days may reduce
the risk of SSI.
CONTROLED OF DIABETES AND HYPERTENSION
Hyperglycemia decreases vit c uptake into cells this can be partially overcome
by supplements at 500-2000 mg /day
Vit A was helpful oral doses 25,000 u/day may overcome the inhibitory effect
of steroids which hinder wound healing
Should showed with antibacterial soap the night before the operation

11. Perioperative Glucose
Control

12. Perioperative Glucose Control
 1,000 cardiothoracic surgery patients
 Diabetics and non-diabetics with hyperglycemia
Patients with
a blood sugar
> 300 mg/dL
during or
within 48
hours of
surgery had
more than 3X
the likelihood
of a wound
infection!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.

13. Pre-operative shaving
 Shaving the surgical site with a razor induces
small skin lacerations
– potential sites for infection
– disturbs hair follicles which are often colonized with S.
aureus
– Risk greatest when done the night before
– Patient education
 It may be best NOT to have patient shave before they come
to the hospital.

14. Prophylactic
Antibiotics
Antibiotics given for
the purpose of preventing
infection when infection is
not present but the risk of
postoperative infection is
present

15. Colon surgery
Oral
Neomycin and metronidazole
IV = Cefoxitin or cefotetan
Cefazolin and metronidazole

16. Cardiothoracic surgery
Cefazolin
Cefuraxime
B-lactam allergy
vancomycin Or clindamycin
24-72 hrs

17. GIT
 Cefazolin or Cefoxitin

18. Trauma related
infection
Hemorrhagic shock
Heavy wound
Contamination
CNS injury
Colon injury
Pts in shock are hypotensive and vasoconstricted and
tissue penetration of antibiotics may be decreased
, blood loss result in antibiotic loss

19. Trauma related
infection
 Narrow spectrum for a defined
period of time (24 hrs)
 1st or 2nd generation cephalosporin
(limited role in the therapy of
infections)
 Higher dosed of antibiotics
 Prolonged antibiotic increased the
risk of subsequent antibiotic
resistant organisms without benefit
to the patients

20. Operating room
environment
 Hand scrubbing
 Antiseptic to the
skin
 Fluid replacement
 Ventilation

21. Maintaining
Normothermia

22. Consequences of Hypothermia
Perioperative patients
 Adverse myocardial outcomes
 1.5º C core temperature decrease triples the risk of
morbid myocardial events
 Coagulopathy
 impairs platelet function and coagulation cascade
 Reduces drug metabolism
 Thermal discomfort (patient satisfaction)
 Surgical wound infection
 thermoregulatory vasoconstriction

23. Temperature Control
– control - routine intra operative thermal care
(mean temp 34.7°C)
– treatment - active warming (mean temp on
arrival to recovery 36.6°C)

24. Supplemental Oxygen
Issues to Consider for
Perioperatively
 Remarkably cheap, readily available
 Little risk of atelectasis or impaired
pulmonary function
 Reduce incidence and severity of
postoperative nausea
 May improve alveolar phagocytosis and
bacterial killing
 Reduce surgical wound infection

25. New active device for
prevention of SSI
 Surgical device manufacturers are
introducing new dual-action or active
platform devices
 Antibacterial sutures (VICRYL plus
antibacterial )
 Polyglactin suture coated with triclosan
 Kerlix antimicrobial dressing
 Acticoat with Silcryst Nanocrystals

26. “Simple precautions can save life.”
THANK YOU