SURGICAL SITE INFECTION

1. SURGICAL SITE INFECTIONS
BY
AMR EMAD EL-DIN AWAD
OBS/GYN Resident
Mansoura University Hospitals
Under supervision of
Prof. OSAMA M. WARDA
Professor of OBS/GYN
Mansoura University
CDC Guideline for the Prevention of Surgical Site Infection, 2017

2. INTRODUCTION
• The ancient Egyptians
had some concept
about infection as
proved by their abilities
to prevent putrefaction
by mummification skills
• Their medical
papyruses also
described salves and
antiseptics

3. INTRODUCTION

4. INTRODUCTION

5. INTRODUCTION

6. Surgical site infections remain among the most common
preventable infections today.
There are 4 medical institution in the US taking the
responsibility with complementary and integrated efforts to
release these guidelines these include:
1- The world health organization
2- the American society of surgeons
3- the surgical infection society
4- the center for disease control
INTRODUCTION

7. The CDC guidelines use a strict process for
literature review, development of consensus,
public reporting, and refinement of their final
recommendations.
This guideline is intended to provide new and
updated evidence-based recommendations for the
prevention of SSI and should be incorporated into
comprehensive surgical quality improvement
programs to improve patient safety.
INTRODUCTION

8. OBJECTIVES
This guideline is intended to provide new and
updated evidence-based recommendations for
the prevention of SSI and should be
incorporated into comprehensive surgical
quality improvement programs to improve
patient safety.

9. EPIDEMIOLOGY
Surgical site infections are
both common and morbid.
Surgical site infections are
now the most common
and costly of all hospital-
acquired infections,
accounting for 20% of all
hospital-acquired
infections.
• Increased length of stay
• 2- to 11-fold increase in
the risk of mortality

10. Surgical site infections (SSIs) :
Infections of the Tissues, Organs, or Spaces
exposed by surgeons during performance
of an invasive procedure.
Infections occurring up to 30 days after
surgery or up to one year after surgery in
patients receiving implants and affecting
either the incision or deep tissue at the
operation site.
EPIDEMIOLOGY

11. • Surgical patients initially seen with more
complex comorbidities and the emergence of
antimicrobial-resistant pathogens increase the
cost and challenge of treating SSIs.
• The prevention of SSI is increasingly important
as the number of surgical procedures
performed continues to rise.
• It has been estimated that approximately half
of SSIs are preventable by application of
evidence-based strategies.
EPIDEMIOLOGY

12. • Incidence : SSIs = 3rd most common
healthcare associated infection (HAI)
accounting for 14-16% of HAIs. Among
surgical patients, SSIs were most
common accounting for ~ 40% of HAI.
About 67% incisional infections (confined
to incision) and 33% organ/space
infections
EPIDEMIOLOGY

13. While advances have been made in
infection control practice including
Improved operating room ventilation,
Sterilization methods, Barriers, Surgical
technique, Availability of antimicrobial
prophylaxis; SSIs remain a substantial
cause of Morbidity, Prolonged
hospitalization and Death.
EPIDEMIOLOGY

14. - Microbial contamination of the surgical site is a
necessary precursor of SSI
- Quantitatively, it has been shown that if a surgical
site is contaminated with >100,000 microorganisms
per gram of tissue, the risk of SSI is markedly
increased.
-The dose of contaminating microorganisms
required to produce infection may be much lower
when foreign material is present at the site.
PATHOGENESIS

15. PATHOGENESIS

16. CLASSIFICATION
Two categories of SSIs:
1- Incisional SSI: Superficial – skin and
subcutaneous & Deep – deeper soft tissue e.g.
fascia, muscles.
2- Organ/Space SSI : Involve any part of the
anatomy (e.g. organ or space) other than incised
body wall layers, that was opened or manipulated
during an operation.

17. CLASSIFICATION

18. SURGICAL WOUND ARE CLASSIFIED INTO:
A- Clean wounds
Class I
- No infection is present
- No hollow viscus is entered
-Only skin micro-flora potentially contaminate the
wound
Class ID
-Wounds are similar except that a prosthetic
device (e.g., mesh or valve) is inserted
CLASSIFICATION

19. B- Clean/contaminated wounds
Class II
- A hollow viscus such as the respiratory,
alimentary, or genitourinary tracts with
indigenous bacterial flora is opened under
controlled circumstances
- Without significant spillage of contents
CLASSIFICATION

20. C- Contaminated wounds
Class III
- Open traumatic wounds encountered early after
injury
- Those with extensive introduction of bacteria into
a normally sterile area of the body due to major
breaks in sterile technique (e.g., open cardiac
massage)
- Gross spillage of viscus contents such as from the
intestine, or incision through inflamed tissue
CLASSIFICATION

21. D- Dirty wounds
Class IV
- Traumatic wounds with significant delay in
treatment and in which necrotic tissue is present
- Those created in the presence of overt
infection (purulent material)
- Those created to access a perforated viscus
with high degree of contamination.
CLASSIFICATION

22. CDC Recommendations
1. Parenteral Antimicrobial Prophylaxis
2. Non-parenteral Antimicrobial Prophylaxis
3. Glycemic Control
4. Normo-thermia
5. Oxygenation
6. Antiseptic Prophylaxis
7. Prosthetic Joint Arthroplasty Section
8. Blood Transfusion
9. Systemic Immunosuppressive Therapy
10. Intra-articular Corticosteroid Injection
11. Anticoagulation
12. Orthopedic Surgical Space Suit
13. Postoperative Antimicrobial Prophylaxis duration With Drain Use

23. Parenteral Antimicrobial Prophylaxis
1- Administer preoperative antimicrobial agents only when
a bactericidal concentration of the agents is established in
the serum and tissues when the incision is made. ( IB)
2-. Administer the appropriate parenteral prophylactic
antimicrobial agents before skin incision in all cesarean
section procedures. ( IA)
3- In clean and clean-contaminated procedures, do not
administer additional prophylactic antimicrobial agent
doses after the surgical incision is closed in the operating
room, even in the presence of evidence a drain. ( IA)

24. Non parenteral Antimicrobial Prophylaxis
1. No solid evidence regarding the benefits and
harms of intraoperative antimicrobial irrigation
(eg, intra-abdominal, deep, or subcutaneous
tissues) for the prevention of SSI.
2. No solid evidence regarding the benefits and
harms of soaking prosthetic devices in
antimicrobial solutions before implantation for
the prevention of SSI.

25. 3. Do not apply antimicrobial agents (ie, ointments,
solutions, or powders) to the surgical incision for the
prevention of SSI. (IB)
4. Application of autologous platelet-rich plasma is not
necessary for the prevention of SSI. ( II)
5. Consider the use of triclosan-coated sutures for the
prevention of SSI ( II)
6. No solid evidence regarding the benefits and harms of
antimicrobial dressings applied to surgical incisions after
primary closure in the operating room for the prevention of
SSI.
Non parenteral Antimicrobial Prophylaxis

26. Glycemic Control
1. perioperative glycemic control and use
blood glucose
target levels less than 200 mg/dL in patients
with and without
diabetes. (IA)
2. No solid evidence regarding the
identification and the benefits of optimal
hemoglobin A1C target levels for the
prevention of SSI in patients with and without
diabetes.

27. Normo-thermia
1. Maintain perioperative normothermia. (IA)
2. No solid evidence to identify the strategies
to achieve and maintain normothermia, the
lower limit of normothermia, or the optimal
timing and duration of normothermia for the
prevention of SSI.

28. Oxygenation
1.No solid evidence regarding the identification
and the benefits of regarding the administration
of increased fraction of inspired oxygen (FIO2) via
endotracheal intubation during only the
intraoperative period in patients with normal
pulmonary function undergoing general
anesthesia for the prevention of SSI.

29. 2. No solid evidence regarding the benefits and
harms of the administration of increased FIO2
via face mask during the perioperative period in
patients with normal pulmonary function
undergoing general anesthesia without
endotracheal intubation or neuraxial anesthesia
(ie, spinal, epidural, or local nerve blocks) for the
prevention of SSI.
Oxygenation

30. Oxygenation
3.For patients with normal pulmonary function
undergoing general anesthesia with
endotracheal intubation, administer increased
FIO2 during surgery and after ex-tubation in the
immediate postoperative period. To optimize
tissue oxygen delivery, maintain perioperative
normothermia and adequate volume
replacement. (IA)

31. 4. Randomized controlled trial evidence suggested
uncertain trade-offs between the benefits and
harms regarding the administration of increased
FIO2 via face mask or nasal cannula during only the
postoperative period in patients with normal
pulmonary function for the prevention of SSI.
5.The search did not identify randomized controlled
trials that evaluated the optimal target level,
duration, and delivery method of FIO2 for the
prevention of SSI.
Oxygenation

32. Antiseptic Prophylaxis
1. Advise patients to shower or bathe (full body) with
soap (antimicrobial or nonantimicrobial) or an
antiseptic agent on at least the night before the
operative day. (IB)
2. Randomized controlled trial evidence suggested
uncertain trade-offs between the benefits and harms
regarding the optimal timing of the preoperative shower
or bath, the total number of soap or antiseptic agent
applications, or the use of chlorhexidine gluconate wash
cloths for the prevention of SSI.

33. 3. Perform intraoperative skin preparation with
an alcohol-based antiseptic agent unless
contraindicated. (IA)
4. Application of a microbial sealant immediately
after intraoperative skin preparation is not
necessary for the prevention of SSI. (II)
Antiseptic Prophylaxis

34. 5. The use of plastic adhesive drapes with or
without antimicrobial properties is not
necessary for the prevention of SSI. (II)
6. Consider intraoperative irrigation of deep or
subcutaneous tissues with aqueous iodophor
solution for the prevention of SSI. Intra-
peritoneal lavage with aqueous iodophor
solution in contaminated or dirty abdominal
procedures is not necessary. (II)
Antiseptic Prophylaxis

35. Blood Transfusion
Do not withhold transfusion of
necessary blood products from
surgical patients as a means to prevent
SSI. ( IB.)

36. Systemic Immunosuppressive Therapy
1. Available evidence suggested uncertain trade-offs
between the benefits and harms of systemic corticosteroid
or other immunosuppressive therapies on the risk of SSI
2. patients receiving systemic corticosteroid or other
immunosuppressive therapy, recommendation 1E applies:
in clean and clean-contaminated procedures do not
administer additional antimicrobial prophylaxis doses after
the surgical incision is closed in the operating room, even
in the presence of a drain. (IA)

37. Anticoagulation
Available evidence suggested
uncertain trade-offs between the
benefits and harms of venous
thromboembolism prophylaxis on the
incidence of SSI.

38. Postoperative Antimicrobial Prophylaxis
Duration With Drain Use
In clean and clean-contaminated procedures, do
not administer additional antimicrobial
prophylaxis doses after the surgical incision is
closed in the operating room, even in the
presence of a drain. (IA)

39. CONCLUSION

40. CONCLUSION

44. Conclusions
The number of unresolved issues in this
guideline reveals substantial gaps that
warrant future research.
A select list of these unresolved issues
may be prioritized to formulate a
research agenda to advance the field.
Adequately powered , well-designed
studies that assess the effect of specific
interventions on the incidence of SSI are
needed to address these evidence gaps.
Subsequent revisions to this guideline
will be guided by new research and
technological advancements for
preventing SSIs

45. Category Specification
Category IA: A strong recommendation supported by high to moderate quality
evidence suggesting net clinical benefits or harms.
Category IB: A strong recommendation supported by low-quality evidence
suggesting net clinical benefits or harms or an accepted practice (eg,
aseptic technique) supported by low to very low–quality evidence.
Category IC: A strong recommendation required by state or federal regulation.
Category II: A weak recommendation supported by any quality evidence
suggesting a trade-off between clinical benefits and harms.
No
recommenda
tion/unresol
ved issue:
An issue for which there is low to very low–quality evidence with
uncertain trade-offs between the benefits and harms or no published
evidence on outcomes deemed critical to weighing the risks and
benefits of a given intervention.
Recommendations were categorized using the following standard system
that reflects the level of supporting evidence or regulations:

46. THANK YOU