Surgical site infection

 Chairperson Elect ICOG –Indian College of OB/GY
 National Corresponding Editor-Journal of OB/GY of India JOGI
 National Corresponding Secretary Association of Medical Women, India
 Founder Patron & President –ISOPARB Vidarbha Chapter 2019-21
 Chairperson-IMS Education Committee 2021-23
 President-Association of Medical Women, Nagpur AMWN 2021-24
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY);
FICOG; FICMU; FICMCH
Medical Director-
Shrikhande Fertility Clinic
Nagpur, Maharashtra
 Nagpur Ratan Award @ hands of Union Minister Shri Nitinji Gadkari
 Received Bharat excellence Award for women’s health
 Received Mehroo Dara Hansotia Best Committee Award for her work as
Chairperson HIV/AIDS Committee, FOGSI 2007-2009
 Received appreciation letter from Maharashtra Government for her work in the
field of SAVE THE GIRL CHILD
 Senior Vice President FOGSI 2012
 President Menopause Society, Nagpur 2016-18
 President Nagpur OB/GY Society 2005-06
Delivered 11 orations and 450 guest lectures
Publications-13 National & 11 International
Sensitized 2 lakh boys and girls on adolescent health issues

Surgical Site Infection
Dr Laxmi Shrikhande
Consultant –Shrikhande Hospital
Nagpur

Post Operative Infection
• The obstetric and gynecological procedures at high risk of post-
operative infection include
• vaginal and abdominal hysterectomy and
• Caesarean section. Guaschino, S., De Santo, D. and De Seta, F. (2002) New perspectives
in antibiotic prophylaxis for obstetric and gynecological surgery.
Journal of Hospital Infection, 50, S513-S516.
• Compared with women delivered vaginally, those delivered by
caesarean section at increase risk of infection (2-20 fold)
Gibbs, R.S. (1980) Clinical risk factors for puerperal infection. Obstetrics & Gynecology, 55, 178S-184S.
Antibiotic Prophylaxis for Gynecologic Procedures, “Practice bulletin No. 104. American College of Obstetricians and Gynecologists,” Obstetrics &
Gynecology, vol. 113, no. 5, pp. 1180–1189, 2009.
W. Jamie and P. Duff, “Preventing infections during elective C/S and abdominal hysterectomy,”Contemporary Obstetrics and Gynecology, vol. 48, no. 1, pp.
60–69, 2003.

Gynaecologic Procedures
Gynaecologic procedures pose a unique challenge in that potential
pathogenic microorganisms from the skin or vagina and endocervix
may migrate to operative sites and can result in
 Vaginal cuff cellulitis,
 Pelvic cellulitis, and
 Pelvic abscesses.

Definition of Pelvic Infections after Gynecologic Surgery
The Centers for Disease Control and
Prevention (CDC) defines a SSI as an
infection occurring within 30 days of an
operation occurring in one of 3 locations:
 superficial at the incision site,
 deep at the incision site, or
 in other organs or spaces opened
or manipulated during an operation
T. C. Horan, R. P. Gaynes, W. J. Martone, W. R. Jarvis, and T. G. Emori, “CDC definitions of nosocomial surgical site infections, 1992:
a modification of CDC definitions of surgical wound infections,” Infection Control and Hospital Epidemiology, vol. 13, no. 10, pp.
606–608, 1992.

Incidence of SSI
 The incidence of SSI varies widely, ranging from 5 to 30 percent
depending upon the operative site and wound classification.
 It is estimated that SSI develops in 2 to 5 percent of patients
undergoing inpatient surgical procedures each year .
 SSIs are associated with increased morbidity and mortality .
 The incidence of SSI has decreased over time due to widespread
prevention efforts.
Garibaldi RA, Burke JP, Dickman ML, Smith CB. Factors predisposing to bacteriuria during indwelling urethral
catheterization. N Engl J Med 1974; 291:215.
Sedor J, Mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol Clin
North Am 1999; 26:821.
Frank SM, Kluger MJ, Kunkel SL. Elevated thermostatic setpoint in postoperative patients. Anesthesiology 2000; 93:1426.

Risk Factors for SSI
 The preoperative evaluation of a patient provides an excellent
opportunity to evaluate for the presence of modifiable and non
modifiable host risk factors for SSIs.
 Obesity specifically in patients with a BMI of greater than 30 or with
depth of subcutaneous tissue greater than 2 cm.
A. G. Lake, A. M. McPencow, M. A. Dick-Biascoechea, D. K. Martin, and E. A. Erekson, “Surgical site infection after hysterectomy,” The
American Journal of Obstetrics and Gynecology, vol. 209, no. 5, pp. 490.e1–490.e9, 2013

Host Risk Factors for SSI
 Diabetes mellitus particularly in patients with perioperative serum
glucose levels greater than 150 mg/dL and preoperative HbA1c
greater than 6.5%.
 Patients with pre existing medical illness such as diabetes should be
medically optimized prior to surgery.
 Preoperative anemia and history of cerebrovascular accidents were
also associated with deep and organ space SSI .

Host Risk Factors for SSI
 There are several other well-documented risk factors for SSI within
the surgical literature including tobacco use, corticosteroid use,
malnutrition, and increased age .
 History of radiation to the surgical site also elevates risk of infection
G. B. Lazenby and D. E. Soper, “Prevention, diagnosis, and treatment of gynecologic surgical site infections,” Obstetrics and Gynecology
Clinics of North America, vol. 37, no. 3, pp. 379–386, 2010.
J. Gerberding, R. Gaynes, T. Horan et al., “National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1990–May
1999, issued June 1999,” The American Journal of Infection Control, vol. 27, no. 6, pp. 520–532, 1999.
R. Anielski and M. Barczynski, “Postoperative wound infec- ´ tions. III. Patient related risk factors,” Przegla¸d lekarski, vol. 55, no. 11, pp. 565–571,
1998.

Host Risk Factors for SSI-BV
 Bacterial vaginosis is associated with a significantly elevated risk of
postoperative infections, specifically vaginal cuff cellulitis.
 Therefore preoperative screening and treatment is an important
deterrent to postoperative infection .
D. E. Soper, “Bacterial vaginosis and postoperative infections,” The American Journal of Obstetrics and
Gynecology, vol. 169, no. 2, pp. 467–469, 1993.
P.-G. Larsson and B. Carlsson, “Does pre- and postoperative metronidazole treatment lower vaginal cuff infection rate after abdominal
hysterectomy among women with bacterial vaginosis?” Infectious Disease in Obstetrics and Gynecology, vol. 10, no. 3, pp. 133–140,
2002.

Surgical Risk Factors -Preoperative
 Prophylactic antibiotics decrease the bacterial inoculum burden on
the skin and make the operative site less hospitable to the growth of
bacteria.
 The antibiotic of choice for prophylaxis should have broad coverage,
be inexpensive, and be easy to administer.
W. Jamie and P. Duff, “Preventing infections during elective C/S and abdominal
hysterectomy,”Contemporary Obstetrics and Gynecology, vol. 48, no. 1, pp. 60–69, 2003.

Preop skin preparation
• Preoperative preparation of the skin and vagina with Povidone-Iodine
or chlorhexidine gluconate is universally recommended to reduce risk
of postoperative cuff cellulitis and abscess.
American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Gynecologic Practice, “Committee Opinion No.
571: solutions for surgical preparation of the vagina,” Obstetrics & Gynecology, vol. 122, no. 3, pp. 718– 720, 2013
A. G. Lake, A. M. McPencow, M. A. Dick-Biascoechea, D. K. Martin, and E. A. Erekson, “Surgical site infection after hysterectomy,” The
American Journal of Obstetrics and Gynecology, vol. 209, no. 5, pp. 490.e1–490.e9, 2013.

Intraoperative Risk Factors
 increased blood loss greater than 500 mL,
 prolonged surgical procedure greater than 140 minutes, and
 blood transfusion
are associated with development of deep and organ space SSI .
A. G. Lake, A. M. McPencow, M. A. Dick-Biascoechea, D. K. Martin, and E. A. Erekson, “Surgical site infection after
hysterectomy,” The American Journal of Obstetrics and Gynecology, vol. 209, no. 5, pp. 490.e1–490.e9, 2013.

Intraoperative Risk Factors.
 Staple closure was associated with significantly increased wound
infectious morbidity compared to closure with sutures in a
randomized control trial by Figueroa et al.
 Fibrillar oxidized regenerated cellulose may contribute to pelvic
abscess formation.
 The hemostatic agent can trap tissue debris, protect bacteria from
host-defense mechanisms, and with unopposed bacterial
proliferation lead to abscess formation .
D. Figueroa, V. C. Jauk, J. M. Szychowski, R. Garner, J. R. Biggio, andW.W. Andrews, “Surgical staples compared with subcuticular suture
for skin closure after cesarean delivery: A randomized controlled trial,” Obstetrics and Gynecology, vol. 121, no. 1, 2013

 For operations performed laparoscopically, direct trocar insertion
and open technique may confer a lower post,infection rate than entry
with the Veress needle .
 Single-port laparoscopic hysterectomy appears to have a lower
infection rate than traditional four-port laparoscopic hysterectomy .
R. Angioli, C. Terranova, C. de Cicco Nardone et al., “A comparison of three different entry techniques in gynecological laparoscopic
surgery: a randomized prospective trial,” European Journal of Obstetrics Gynecology and Reproductive Biology, vol. 171, no. 2, pp. 339–
342, 2013.
M. Li, Y. Han, and Y. C. Feng, “Single-port laparoscopic hysterectomy versus conventional laparoscopic hysterectomy: a prospective
randomized trial,” Journal of International Medical Research, vol. 40, no. 2, pp. 701–708, 2012.

 Removal of fallopian tubes at the time of hysterectomy may also
significantly decrease the risk of infectious complications .
 Robotic-assisted procedures do not appear to confer any advantage
versus convention laparoscopy from an infectious standpoint
F. Ghezzi, A. Cromi, G. Siesto, V. Bergamini, F. Zefiro, and P. Bolis, “Infectious morbidity after total laparoscopic hysterectomy: does concomitant
salpingectomy make a difference?” BJOG: An International Journal of Obstetrics & Gynaecology, vol. 116, no. 4, pp. 589–593, 2009.
E. B. Rosero, K. A. Kho, G. P. Joshi, M. Giesecke, and J. I. Schaffer, “Comparison of robotic and laparoscopic hysterectomy for benign gynecologic
disease,” Obstetrics and Gynecology, vol. 122, no. 4, pp. 778–786, 2013

• Patients undergoing pelvic lymphadenectomy, paraaortic
lymphadenectomy, splenectomy, bowel resection, or pelvic
exenteration for surgical treatment of gynecologic malignancies are
associated with increased risk of deep superficial and organ space
SSIs
J. N. Bakkum-Gamez, S. C. Dowdy, B. J. Borah et al., “Predictors and costs of surgical site infections in patients with endometrial
cancer,” Gynecologic Oncology, vol. 130, no. 1, pp. 100–106, 2013.
A. Fagotti, B. Costantini, F. Fanfani et al., “Risk of postoperative pelvic abscess in major gynecologic oncology surgery:
one-year single-institution experience,” Annals of Surgical Oncology, vol. 17, no. 9, pp. 2452–2458, 2010

Postoperative Risk Factors.
 Postoperative anemia has been defined as a significant risk factor for
all classifications of SSI in obstetrical and gynecologic surgery .
 Poor glucose control, defined as levels greater than 200 mg/dL within
the first 48 hours postoperatively, increased the likelihood of pelvic
infections .
 Increased length of duration of hospital stay perioperatively has also
been correlated with increased incidence of SSIs .
T. A. Jido and I. D. Garba, “Surgical-site infection following Cesarean section in Kano, Nigeria,” Annals of Medical and Health Sciences Research, vol.
2, no. 1, pp. 33–36, 2012.
A. J. Mangram, T. C. Horan, M. Pearson et al., “Guideline for prevention of surgical site infection,” Infection Control and Hospital Epidemiology, vol.
20, no. 4, pp. 247–264, 1999
G. B. Lazenby and D. E. Soper, “Prevention, diagnosis, and treatment of gynecologic surgical site infections,” Obstetrics and Gynecology Clinics of
North America, vol. 37, no. 3, pp. 379–386, 2010.

Clinical evaluation
• The febrile postoperative patient should be evaluated systematically .
History — Review the medical record for a history of fever following
prior surgeries.

History-Recent medical history:
 Was fever present prior to surgery?
 Are there symptoms or signs associated with the fever?
 Have household contacts had fever recently?
 Has the patient traveled to areas where endemic or epidemic
infectious diseases occur?
 Has the patient had other recent procedures or initiated new drugs
prior to surgery?

History-Review the patient record for:
 History of fever after previous surgeries
 Preoperative course and presentation
 Details of the operation (date of surgery, emergency or elective,
intraoperative complications, anesthesia record)
 Postoperative course
 Allergies
 Medications (in particular, review new medications given for surgery, such
as anesthetics, antibiotics, pain medications, medications that suppress the
magnitude of fever [eg, nonsteroidal anti-inflammatory drugs,
glucocorticoids])
 Transfusions
 Location and type of catheters and timing/verifications of placement

History Taking-Ask the patient and nurse about:
 Pain
 Sputum production, quality, and volume
 Presence of diarrhea
 Urinary symptoms
 Drainage from surgical site or around drains
 Condition of any intravenous or bladder catheter sites
 Skin changes (areas of skin breakdown, rash, purpura/bruising,
erythema, and pallor)

Physical examination
 Review the record of the patient's vital signs, including temperature,
heart rate, and respiratory rate.
 Determine temperature range in the past day and peak daily
temperature values during the hospital stay.
 Check nurses' notes for fevers not recorded in the vital signs record
and other transient patient symptoms and signs.

Physical examination
• Examine the skin for rash, erythema, ecchymosis, hematoma, and pallor.
• Auscultate the lungs for crackles, wheezes, and for the absence of breath
sounds in dependent and apical regions.
• Auscultate the heart for murmurs, gallops, and rubs.
• Evaluate the abdomen for tenderness, distention, and hyper- or hypoactive
bowel sounds.
• Examine the surgical site for erythema, swelling, tenderness, and drainage.
• Examine catheter, tube, and drain sites for erythema, swelling, tenderness,
and drainage.
• Evaluate the extremities for edema, erythema, duskiness, and tenderness.

Physical examination-Inspection of Surgical
sites/tubes/drains —
Thorough physical examination is warranted in patients with
postoperative fever.
 In particular, pay special attention to the surgical site.
 Surgical sites should always be examined, even in the immediate post-
operative phase.
 Also, symptomatic non operative areas of the body (painful areas, for
example) should be examined thoroughly.

Evaluate for common causes
 The febrile postoperative patient should be evaluated systematically
depending on the timing of fever , taking into account the timing of
the onset of fever and the many possible causes .
 Although the list of causes of postoperative fever is extensive, the
initial focus for most patients should be on a limited number of the
more common possibilities suggested by the history and physical
examination and the timing of fever onset.
Badillo AT, Sarani B, Evans SR. Optimizing the use of blood cultures in the febrile postoperative patient. J Am Coll Surg 2002;
194:477.
Schwandt A, Andrews SJ, Fanning J. Prospective analysis of a fever evaluation algorithm after major gynecologic surgery.
Am J Obstet Gynecol 2001; 184:1066.

Evaluate for common causes-- the 5 Ws
A useful initial screen for the more common causes of postoperative
fever is represented by the following mnemonic (the 5 Ws), the order
of which implies the timing of postoperative fever:
"Wind" refers to pulmonary causes of fever, including pneumonia,
aspiration, and pulmonary embolism (but not atelectasis).
"Water" refers to urinary tract infection.
"Wound" refers to surgical site infection.
"Walking" refers to venous thromboembolism.
"Wonder drugs" refers to drug-related fever.

Evaluate for common causes-other Ws
Other Ws have been proposed, including
 "Waves,“
 "Wonky glands,"
 "Withdrawal," and
 "What did we do?" .
These are reminders to consider cardiac and endocrine causes; alcohol and other
substance withdrawal; and other treatments such as medications, blood product
transfusions, and intravascular, urethral, nasal, and abdominal catheters as potential causes
for a patient's postoperative fever.
Hyder JA, Wakeam E, Arora V, et al. Investigating the "Rule of W," a mnemonic for teaching on postoperative
complications. J Surg Educ 2015; 72:430.

 Atelectasis has often been used as an explanation for early
postoperative fever.
 Both atelectasis and fever occur frequently after surgery, but their
concurrence is probably coincidental rather than causal .
Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest 2011;
140:418.
Roberts J, Barnes W, Pennock M, Browne G. Diagnostic accuracy of fever as a measure of postoperative pulmonary complications.
Heart Lung 1988; 17:166.
Engoren M. Lack of association between atelectasis and fever. Chest 1995; 107:81.

• Self-limited fever is common following most major surgeries .
• Fever-associated cytokines are released by tissue trauma and do not
necessarily signal infection.
• The magnitude of the trauma is correlated with the degree of the
fever response.
• This fever resolves within two to three days.
• The severity and duration of these self-limited postoperative fevers
depends on the type of surgery but tend to be greater in patients
with longer and more extensive surgical procedures .
Crompton JG, Crompton PD, Matzinger P. Does Atelectasis Cause Fever
After Surgery? Putting a Damper on Dogma. JAMA Surg 2019; 154:375.

• Medication reaction — Febrile drug reactions are a frequent cause of
postoperative fever and may be accompanied by hypotension or rash.
• Antimicrobials - Beta-lactam antibiotics and sulfa-containing products
• Heparin
• H2-blockers,
• procainamide,
• phenytoin, .
• In addition, antimicrobials and other medications incorporated into implanted
materials may cause postoperative fever
Cobb WS, Paton BL, Novitsky YW, et al. Intra-abdominal placement of antimicrobial-impregnated mesh is associated
with noninfectious fever. Am Surg 2006; 72:1205.

• Transfusion reaction — Transfusion reactions, such as delayed
serologic and hemolytic transfusion reactions, are more common in
patients previously sensitized to foreign antigens through prior
transfusion or multiple pregnancies
Ness PM, Shirey RS, Weinstein MH, King KE. An animal model for delayed hemolytic transfusion reactions. Transfus Med
Rev 2001; 15:305.
Kopko PM, Marshall CS, MacKenzie MR, et al. Transfusion-related acute lung injury: report of a clinical look-back
investigation. JAMA 2002; 287:1968.

 Surgical site infection — Surgical site infection (SSI) most often
presents in the late postoperative period, one week or more after
surgery.
 Many patients have already been discharged from the hospital by this
time .
 In addition, for patients who have new anastomoses, staple lines or
ligated ducts may develop a leak that manifests as an SSI.
Friedman C, Sturm LK, Chenoweth C. Electronic chart review as an aid to postdischarge surgical site surveillance: increased case
finding. Am J Infect Control 2001; 29:329.
Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996; 173:963.
Delgado-Rodríguez M, Gómez-Ortega A, Sillero-Arenas M, Llorca J. Epidemiology of surgical-site infections diagnosed after
hospital discharge: a prospective cohort study. Infect Control Hosp Epidemiol 2001; 22:24.

 Nosocomial infection constitutes a major public health problem
worldwide.
 The most common types of nosocomial infections that could occur in
a hospital set up are
 surgical wound and other soft tissue infections,
 urinary tract,
 respiratory and
 blood stream infections.
Graves N. The cost of hospital acquired infections Unit costs of health and social care. 2000:25-27
Centers for Disease Control (CDC) Surgical Site Infection (SSI) Event. 2016. Available at: http://www.cdc.gov/nhsn/pdfs/pscmanual/
9pscssicurrent.pdf. Accessed Aug. 26, 2016.

Nosocomial Infection
• Prolonged preoperative hospitalization should be avoided to decrease
the risk of patients becoming colonized with nosocomial bacteria, as
these microorganisms tend to be more resistant to antibiotics
compared to endogenous bacteria
A. B. Cavanillas, R. Rodr`ıguez-Contreras, M. D. Rodriguez et al., “Preoperative stay as a risk factor for
nosocomial infection,” European Journal of Epidemiology, vol. 7, no. 6, pp. 670–676, 1991.

Clinical Features and Management of SSI
Typically, postoperative pelvic infections, including vaginal cuff cellulitis and
pelvic abscess, present with
 complaint of pelvic pain
 with fever
 with associated tachycardia
 and leukocytosis.
J. Oteo, B. Aracil, J. I. Alos, and J. L. G ´ omez-Garc ´ es, “High ´ prevalence of resistance to clindamycin in Bacteroides fragilis
group isolates,” Journal of Antimicrobial Chemotherapy, vol. 45, no. 5, pp. 691–693, 2000

Vaginal Cuff Cellulitis
 Vaginal cuff cellulitis is an infection of the superficial tissues at the
vaginal surgical margin after vaginal hysterectomy.
 Patients typically present after hospital discharge with moderate, but
increasing, lower abdominal pain with purulent yellow vaginal
discharge.
 Physical examination will reveal the vaginal surgical margin to be
tenderness out of proportion to what is expected with hyperemia and
edema.
 The adnexa and parametria are nontender.
D. L. Stevens, A. L. Bisno, H. F. Chambers et al., “Practice guidelines for the diagnosis and management of skin and soft tissue infections,” Clinical
Infectious Diseases, vol. 41, no. 10, pp. 1373–1406, 2005
C. Faro and S. Faro, “Postoperative pelvic infections,” Infectious Disease Clinics of North America, vol. 22, no. 4, pp. 653–663, 2008.

Pelvic Cellulitis
 Patient with pelvic cellulitis typically presents 5 to 10 days after
surgery with fever, vague abdominal pain, or the sensation of pelvic
fullness.
 Associated symptoms may include anorexia, but they typically do not
have gastrointestinal or urinary complaints.
 Physical examination will reveal regional tenderness to palpation,
with edema in the absence of masses or peritoneal signs.
 Ultrasound will demonstrate no masses.

Pelvic Abscess
 Pelvic abscesses are a rare but serious complication of pelvic surgery
occurring when pelvic cellulitis or pelvic hematoma spread into the
parametrial soft tissue .
 Pelvic abscess symptoms mirror that of pelvic cellulitis, with the
addition of a palpable mass corresponding to the collection of
infected fluid or visualization of the fluid collection by USG, CT, or
MRI.
C. Faro and S. Faro, “Postoperative pelvic infections,” Infectious Disease Clinics of North America, vol. 22, no. 4, pp. 653–663, 2008.

Measures to reduce risk of SSI —
Surgeons can reduce rates of SSI using preventive measures that
include
 avoiding elective surgery in patients with active infection,
 timely administration of prophylactic antibiotics,
 proper skin preparation, and
 maintenance of sterile conditions .
Galicier C, Richet H. A prospective study of postoperative fever in a general surgery department. Infect Control 1985; 6:487.

Measures to reduce risk of SSI —Good surgical
technique
 gentle traction,
 effective hemostasis,
 removal of devitalized tissues,
 obliteration of dead space,
 irrigation of tissues with saline to avoid excessive drying,
 wound closure without tension, and
 minimizing duration of closed-suction drainage .
 The judicious use of electrosurgery to reduce thermal damage to tissue.
 Excessive use can cause areas of tissue necrosis that can serve as a nidus for infection.
Kane TD, Alexander JW, Johannigman JA. The detection of microbial DNA in the blood: a sensitive method for diagnosing bacteremia
and/or bacterial translocation in surgical patients. Ann Surg 1998; 227:1.
O'Grady NP, Barie PS, Bartlett JG, et al. Practice guidelines for evaluating new fever in critically ill adult patients. Task Force of the
Society of Critical Care Medicine and the Infectious Diseases Society of America. Clin Infect Dis 1998; 26:1042.

Various topical and local antibiotic delivery methods have been used
to reduce the incidence of SSI, including
 antibiotic irrigation,
 topical antimicrobial agents,
 antibiotic sutures, and
 antimicrobial dressings.
 Despite a wide array of delivery systems to deliver antibiotics near
implants, few have found their way into routine clinical practice.

• A wide variety of surgical drains have also been used to prevent SSI,
including closed suction drains within an anatomic space (eg,
peritoneal cavity, joint space).
• In addition, open or closed system surgical drains have been used in
the subcutaneous space to prevent SSI.
• there are insufficient data to support the routine use of drains for the
prevention of SSI .
Mungai M, Tegtmeier G, Chamberland M, Parise M. Transfusion-transmitted malaria in the United States from 1963 through
1999. N Engl J Med 2001; 344:1973.
Dodd RY. Transmission of parasites by blood transfusion. Vox Sang 1998; 74 Suppl 2:161.

• Furthermore, with the advent of Enhanced Recovery after Surgery
protocols, the routine use of surgical drains has been discouraged
given the negative impact of surgical drains/tubes on early
mobilization after surgery .
Tan FL, Loo WL, Tan SG, et al. Severe acute respiratory syndrome in surgical patients: a diagnostic dilemma.
ANZ J Surg 2005; 75:21.

 Prophylactic negative pressure wound therapy (NPWT; ie, overlying
a closed incision) has been described with the aim of preventing SSI .
 While data are promising for certain high-risk surgeries and
contaminated wounds, the evidence does not uniformly support its
use.
 Outcomes likely vary due to the degree of contamination and features
related to the incision site .
Tan FL, Loo WL, Tan SG, et al. Severe acute respiratory syndrome in surgical patients: a diagnostic dilemma.
ANZ J Surg 2005; 75:21.

 Leaving the wound open at the primary operation for delayed
primary closure is another strategy used to reduce the risk for SSI .
 Although observational studies have supported this practice, a meta-
analysis of randomized trials did not demonstrate a benefit to delayed
primary closure ; even class III and IV contaminated wounds may be
safe for primary closure .
Wallace WC, Cinat ME, Nastanski F, et al. New epidemiology for postoperative nosocomial infections. Am Surg 2000;
66:874.
Caplan ES, Hoyt NJ. Nosocomial sinusitis. JAMA 1982; 247:639.

 Anticipatory management of wounds at high risk for postoperative
seroma and SSI is possible with loosely stapled skin closure and daily
probing between the staples with a cotton-tipped applicator until the
wound is impenetrable .
 Alternatively, a negative pressure wound dressing applied directly to the
approximated wound can evacuate accumulated wound drainage and
minimize seroma formation and is also thought to increase blood flow to
the wound edges to promote healing.
Borman KR, Brown PM, Mezera KK, Jhaveri H. Occult fever in surgical intensive care unit patients is seldom caused by
sinusitis. Am J Surg 1992; 164:412.

 There is no evidence to suggest that use of any particular wound
dressing over a closed surgical wound has any effect on the rate of SSI
; however,
 wound protectors, which are designed to protect the wound edges
from trauma and contamination, may be warranted for prevention of
SSI in the setting of clean-contaminated, contaminated, and dirty
abdominal procedures .
 Wound protectors are available for laparotomy and laparoscopic
incisions and orthopedic incisions

Summary and Recommendations-SSI
 Fever (>38°C [100.4°F]) is common in immediate and early
postoperative period.
 This febrile response may be due to tissue trauma with cytokine
release, circulating bacterial endotoxins from endogenous gut flora,
or other causes.
 Inpatients with perioperative fever should be evaluated with a history
and a physical exam to ensure that there is no preexisting cause of
infection or a rapidly progressive surgical site infection.
 Other sources, such as medication reactions, should be ruled out.
 In most other patients, no further diagnostic testing is required.

Summary and Recommendations-SSI
 Starting with postoperative day 4, the differential diagnosis of fever in
the surgical patient evolves to include infectious and noninfectious
etiologies .
 Surgical site infection, pneumonia, urinary tract infection, and
intravascular catheter infection are the predominant infectious causes
of fever following surgery and are often due to nosocomial multidrug-
resistant organisms.
 The most common noninfectious cause of fever in the surgical patient
is a medication reaction ; antimicrobial agents or heparin are the
drugs most frequently implicated.

Summary and Recommendations-Pelvic surgery
 Postoperative cuff and pelvic abscesses are among the most common
complications of gynecologic surgeries.
 Evaluation for preoperative and postoperative risk factors and managing
modifiable risk factors can decrease infection rates.
 Pelvic abscesses are usually polymicrobial and contain both aerobic and
anaerobic bacteria.
 Pelvic cellulitis typically presents 5 to 10 days after surgery with fever,
vague abdominal pain, or the sensation of pelvic fullness. Pelvic abscess
symptoms mirror that of pelvic cellulitis with the addition of a palpable
mass corresponding to the collection of infected fluid or radiographic
evidence of abscess.

Summary and Recommendations-Maternal
Sepsis
 Sepsis remains a major cause for the admission of pregnant women to the
intensive care unit and is a leading cause of maternal morbidity and
mortality.
 The causes of maternal sepsis include obstetric and non-obstetric causes.
 Maternal sepsis may also be from obstetrical critical illness.
 The most commonly reported pathogens in maternal sepsis include E. coli,
Streptococcus, Staphylococcus, and other gram-negative bacteria.
 The management of sepsis during pregnancy should follow the same basic
principles as that in the nonpregnant population, including early
recognition, fluid therapy, timely broad-spectrum antibiotics, and source
control

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Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

The Art of Living
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unconditionally happy
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Surgical site infection

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