LETS KNOW ABOUT - SURGICAL SITE INFECTION(SSI). Infections of the incision or organ or space, that occur after surgery. 60% of SSIs -preventable with evidence-based guidelines. MC and costliest hospital-acquired infections, 20% of all hospital infections. CLAClassified based on the depth and tissue layers . Superficial incisional SSI Primary or secondary. Deep incisional SSI Primary or secondary. Organ/space SSI SUPERFICIAL INCISIONAL SSI Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and had at least one of the following: a. Purulent drainage from the superficial incision. b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. c. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon and is culture positive or not cultured. A culture-negative finding does not meet this criterion. d. Diagnosis of superficial incisional SSI by the surgeon or attending physician DEEP INCISIONAL SSI Infection occurs within 30 days after the operative procedure if no implant is left in place or within 3 months if implant is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and patient has at least one of the following: a. Purulent drainage from the deep incision but not from organ/space component of the surgical site. b. Deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured when the patient has at least one of the following signs or symptoms: fever (>38°C) or localized pain or tenderness. A culture-negative finding does not meet this criterion. c. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination. d. Diagnosis of a deep incisional SSI by a surgeon or attending physician.Wound that has both superficial and deep incisional infection is classified as DIS ORGAN SPACE SSI Infection occurs within 30 days after the operative procedure if no implant is left in place or within 3 months if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least one of the following: a. Purulent drainage from a drain that is placed through a stab wound into the organ/space. b. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. c. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination. Tyu

1. SURGICAL SITE
INFECTIONS.
PRESENTER
DR LALKRISHNA MULWANI
DNB RESIDENT,GENERAL SURGERY.
TATA MOTORS HOSPITAL, JAMSHEDPUR

2. LETS KNOW ABOUT - SURGICAL SITE INFECTION(SSI)
• Infections of the incision or organ or space, that occur after surgery.
• 60% of SSIs -preventable with evidence-based guidelines.
• MC and costliest hospital-acquired infections, 20% of all hospital infections.

3. CLASSIFICATION
Classified based on the depth and tissue layers .
• Superficial incisional SSI
• Primary or secondary.
• Deep incisional SSI
• Primary or secondary.
• Organ/space SSI

4. SUPERFICIAL INCISIONAL SSI
• Infection occurs within 30 days after the operative procedure and involves only
skin and subcutaneous tissue of the incision and had at least one of the
following:
• a. Purulent drainage from the superficial incision.
• b. Organisms isolated from an aseptically obtained culture of fluid or tissue
from the superficial incision.
• c. At least one of the following signs or symptoms of infection: pain or
tenderness, localized swelling, redness, or heat, and superficial incision is
deliberately opened by surgeon and is culture positive or not cultured. A
culture-negative finding does not meet this criterion.
• d. Diagnosis of superficial incisional SSI by the surgeon or attending physician

6. DEEP INCISIONAL SSI
• Infection occurs within 30 days after the operative procedure if no implant is left in place or within 3
months if implant is in place and the infection appears to be related to the operative procedure and
involves deep soft tissues (e.g., fascial and muscle layers) of the incision and patient has at least one of
the following:
• a. Purulent drainage from the deep incision but not from organ/space component of the surgical site.
• b. Deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive
or not cultured when the patient has at least one of the following signs or symptoms: fever (>38°C) or
localized pain or tenderness. A culture-negative finding does not meet this criterion.
• c. An abscess or other evidence of infection involving the deep incision is found on direct examination,
during reoperation, or by histopathologic or radiologic examination.
• d. Diagnosis of a deep incisional SSI by a surgeon or attending physician.Wound that has both
superficial and deep incisional infection is classified as DIS

8. ORGAN SPACE SSI
• Infection occurs within 30 days after the operative procedure if no implant is left in place or
within 3 months if implant is in place and the infection appears to be related to the operative
procedure and infection involves any part of the body, excluding the skin incision, fascia, or
muscle layers, that is opened or manipulated during the operative procedure and patient has at
least one of the following:
• a. Purulent drainage from a drain that is placed through a stab wound into the organ/space.
• b. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
• c. An abscess or other evidence of infection involving the organ/space that is found on direct
examination, during reoperation, or by histopathologic or radiologic examination.
• d. Diagnosis of an organ/space SSI by a surgeon or attending physician

9. RISK FACTORS
• Patient Factors
• Non modifiable
• Age ,malignancy , immunosuppression
• Recent or existing infection
• Recent radiotherapy or steroid therapy
• Chronic inflammation , obesity
• Peripheral vascular disease
• Ascites
• Modifiable
• Smoking , alcoholism
• Malnutrition, post op anaemia
• Hyperbilirubineima
• hypercholesterolemia
• Hypoxemia ,hypoalbuminemia

10. • Environmental Factors
• Contamination
• Inadequate antisepsis
• Inadequate disinfection
• Inadequate ventilation
• Increased operating room traffic
• Treatment Factors
• Blood transfusion
• Contamination: poor scrubbing technique,
breach in asepsis, poor gloving, etc.
• Drains
• Emergency surgery
• High wound classification
• Hypothermia,Hypoxemia
• Inadequate or inappropriate antibiotic
prophylaxis
• Poor glycemic control
• Prolonged operation

11. CDC SURGICAL WOUND CLASSIFICATION
• I—Clean
An uninfected operative wound in which no inflammation is encountered and the
respiratory, alimentary, genital, or uninfected urinary tract is not entered. In
addition, clean wounds are primarily closed and, if necessary, drained with closed
drainage. Operative incisional wounds that follow no penetrating (blunt) trauma
should be included in this category if they meet the criteria.

12. II—Clean-contaminated
An operative wound in which the respiratory, alimentary, genital, or urinary tracts
are entered under controlled conditions and without unusual contamination.
Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx
are included in this category, provided no evidence of infection or major break in
technique is encountered

13. • III—Contaminated
• Open, fresh, accidental wounds. In addition, operations with major breaks in
sterile technique (e.g., open cardiac massage) or gross spillage from the
gastrointestinal tract and incisions in which acute, no purulent inflammation is
encountered are included in this category.

14. • IV—Dirty
• Infected Old traumatic wounds with retained devitalized tissue and those that
involve existing clinical infection or perforated viscera. This definition suggests
that the organisms causing postoperative infection were present in the operative
field before the operation

15. MANAGEMENT STRATIGIES
• 1. Pathogen identification.
• 2. Source control by opening the incision in superficial or deep surgical site
infection(SSIs) or by image-guided percutaneous drainage, laparoscopic, or open
drainage if indicated in organ space SSIs.
• 3. Immediate empiric antibiotic coverage.
• 4. Timely antibiotic de-escalation.
• 5. Local wound care.

16. CENTERS FOR DISEASE CONTROL AND PREVENTION
GUIDELINE FOR SURGICAL SITE INFECTION 2017

17. Q1. RECOMMENDATIONS PARENTERAL ANTIMICROBIAL PROPHYLAXIS (AMP)
• 1A. Administer preoperative antimicrobial agent(s) only when indicated, based on published clinical practice guidelines and timed
such that a bactericidal concentration of the agent(s) is established in the serum and tissues when the incision is made. (Category IB
– strong recommendation; accepted practice)
• 1A1. No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes. (No
recommendation/unresolved issue)
• 1B. Administer the appropriate parenteral prophylactic antimicrobial agent(s) prior to skin incision in all cesarean section
procedures. (Category IA – strong recommendation; high-quality evidence)
• 1C. The search did not identify randomized controlled trials evaluating the harms and benefits of weight-adjusted AMP dosing and its
affect on the risk of SSI. Other organizations have made recommendations based on observational and pharmacokinetic data and a
summary of these recommendations can be found in the Other guidelines section of the narrative summary for this question. (No
recommendation/unresolved issue)
• 1D. The search did not identify sufficient randomized controlled trial evidence to evaluate the harms and benefits of intraoperative
redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI. Other organizations have made recommendations
based on observational data and a summary of these recommendations can be found in the Other guidelines section of the narrative
summary for this question. (No recommendation/unresolved issue).
• 1E. 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 a drain. (Category IA – strong recommendation; high-quality
evidence) .

18. Q2. RECOMMENDATIONS NON-PARENTERAL ANTIMICROBIAL PROPHYLAXIS
• 2A.1. Randomized controlled trial evidence suggests uncertain tradeoffs between the benefits and harms regarding intraoperative
antimicrobial irrigation (e.g., intra-abdominal, deep or subcutaneous tissues) for the prevention of SSI. Other organizations have made
recommendations based on the existing evidence and a summary of these recommendations can be found in the Other Guideline
section of the narrative summary for this question. (No recommendation/unresolved issue)
• 2A.2. The search did not identify randomized controlled trials evaluating soaking prosthetic devices in antimicrobial solutions prior to
implantation for the prevention of SSI. (No recommendation/unresolved issue)
• 2B.1. Do not apply antimicrobial agents (i.e., ointments, solutions, or powders) to the surgical incision for the prevention of SSI.
(Category IB – strong recommendation; low-quality evidence)
• 2B.2. Application of autologous platelet-rich plasma is not necessary for the prevention of SSI. (Category II – weak recommendation;
moderate-quality evidence suggesting a trade-off between clinical benefits and harms)
• 2C. Consider the use of triclosan-coated sutures for the prevention of SSI. (Category II – weak recommendation; moderate-quality
evidence suggesting a trade-off between clinical benefits and harms)
• 2D. Randomized controlled trial evidence suggests uncertain tradeoffs between the benefits and harms regarding antimicrobial
dressings applied to surgical incisions following primary closure in the operating room for the prevention of SSI. (No
recommendation/unresolved issue)

19. Q3. RECOMMENDATIONS -GLYCEMIC CONTROL
3A.1. Implement perioperative glycemic control and use blood glucose target levels <200 mg/dL in diabetic and non-diabetic
patients. (Category IA – strong recommendation; high to moderate-quality evidence)
3A.2. The search did not identify randomized controlled trials evaluating lower (<200 mg/dL) or narrower blood glucose target
levels than recommended in this guideline, nor the optimal timing, duration, or delivery method of perioperative glycemic control
for the prevention of SSI. Other organizations have made recommendations based on the existing evidence and a summary of
these recommendations can be found in the Other guidelines section of the narrative summary for this question. (No
recommendation /unresolved issue)
3B. The search did not identify randomized controlled trials evaluating the optimal hemoglobin A1c target levels for the
prevention of SSI in diabetic and non-diabetic patients. (No recommendation/unresolved issue)

20. • Q4. Recommendation -4. Maintain perioperative normothermia. (Category IA –
strong recommendation; high to moderate- quality evidence)
• Q5. Recommendation -5. The search did not identify randomized controlled trials
evaluating strategies to achieve and maintain normothermia, the lower limit of
normothermia, or the optimal timing and duration of normothermia for the
prevention of SSI. Other organizations have made recommendations based on
observational data and a summary of these recommendations can be found in
the Other guidelines section of the narrative summary for this question. (No
recommendation/unresolved issue)

21. Q6. RECOMMENDATIONS-OXYGENATION
• 6A. Randomized controlled trial evidence suggests uncertain tradeoffs between the benefits and harms 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. (No recommendation/unresolved issue)
• 6B. For patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation,
administer increased FiO2 intraoperatively and post-extubation in the immediate postoperative period. To optimize
tissue oxygen delivery, maintain perioperative normothermia and adequate volume replacement. (Category IA – strong
recommendation; moderate quality evidence)
• 6C. Randomized controlled trial evidence suggests uncertain tradeoffs between the benefits and harms regarding the
administration of increased FiO2 via facemask during the perioperative period in patients with normal pulmonary
function undergoing general anesthesia without endotracheal intubation or neuraxial anesthesia (i.e., spinal, epidural,
or local nerve blocks) for the prevention of SSI. (No recommendation/unresolved issue)
• 6D. Randomized controlled trial evidence suggests uncertain tradeoffs between the benefits and harms regarding the
administration of increased FiO2 via facemask or nasal cannula during only the postoperative period in patients with
normal pulmonary function for the prevention of SSI. (No recommendation/unresolved issue)

22. • Q7. Recommendation 7. The search did not identify randomized controlled
trials evaluating the optimal target level, duration, and delivery method of
FiO2 for the prevention of SSI. Other organizations have made
recommendations based on observational data and a summary of these
recommendations can be found in the Other guidelines section of the
narrative summary for this question. (No recommendation/ unresolved
issue)

23. Q8. RECOMMENDATIONS
• 8A. Advise patients to shower or bathe (full body) with soap (antimicrobial or non-antimicrobial) or an antiseptic
agent on at least the night before the operative day. (Category IB – strong recommendation; accepted practice)
• 8A.1. Randomized controlled trial evidence suggests uncertain tradeoffs 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 washcloths for the prevention of SSI. (No recommendation/unresolved issue)
• 8B. Perform intraoperative skin preparation with an alcohol-based antiseptic agent, unless contraindicated.
(Category IA – strong recommendation; high-quality evidence)
• 8C. Application of a microbial sealant immediately following intraoperative skin preparation is not necessary for the
prevention of SSI. (Category II – weak recommendation; low-quality evidence suggesting a trade-off between
clinical benefits and harms)
• 8D. The use of plastic adhesive drapes with or without antimicrobial properties, is not necessary for the prevention
of SSI. (Category II – weak recommendation; high to moderate-quality evidence suggesting a trade-off between
clinical benefits and harms)

24. • Q9. Recommendation 9A. 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. (Category II – weak
recommendation; moderate-quality evidence suggesting a trade-off between clinical benefits and harms)
• 9B. The search did not identify randomized controlled trials evaluating the soaking of prosthetic devices
in antiseptic solutions prior to implantation for the prevention of SSI. (No recommendation/unresolved
issue)
• Q10. Recommendation 10. RCT evidence is insufficient to evaluate the tradeoffs between the benefits and
harms of repeat application of antiseptic agents to the patient’s skin immediately prior to closing the
surgical incision for the prevention of SSI. (No recommendation/unresolved issue).

25. THANK YOU
REFRENCES
• Love and Bailey A short textbook of surgery-28 ed.
• Sabiston Text book of surgery -21st ed.
• Berríos-Torres SI, Umscheid CA, Bratzler DW, et al; Healthcare Infection Control
Practices Advisory Committee. Centers for Disease Control and Prevention
guideline for the prevention of surgical site infection,2017.
JAMASurg.doi:10.1001/jamasurg.2017.0904.