A surgical site infection is an infection that occurs in the wound created by an invasive surgical procedure. There are three main types of SSI: superficial incisional, deep incisional, and organ/space. Risk factors include patient comorbidities, local wound factors, and microbial factors such as wound class. Prevention focuses on pre-op skin preparation and antibiotics, aseptic technique during surgery, and clean wound care post-op. Severe infections can progress to sepsis, severe sepsis, and multiple organ dysfunction syndrome if not properly treated.

1. SURGICAL INFECTION

2. SURGICAL SITE INFECTION
Definition:
A surgical site infection is an infection that occurs in the wound created by an invasive surgical procedure.
 Types of SSI:
• Superficial incisional SSI
• Deep incisional SSI
• Organ / space SSI

3. SUPERFICIAL INCISIONAL SSI
• Infection occurs within 30 days after surgical procedure
• Involves only skin and subcutaneous tissue of the incision
• Patient has at least 1 of the following:
• a. Purulent drainage from the superficial incision
• b. Organism isolated from an aseptically-obtained culture of fluid or tissue
• c. signs or symptoms: pain or tenderness, localized swelling, redness, heat
• d. Diagnosis of superficial SSI by surgeon or attending physician

4. DEEP INCISIONAL SSI
• Infection occurs within 30 days after the operation if no implant is left in place or
within 1 yr. if implant is in place and the infection appears to be related to the
operation.
• Involves deep soft tissues of the incision, e.g., fascial & muscle layers
• Patient has at least 1 of the following:
a. Purulent drainage from deep incision
b. Deep incision spontaneously dehisces or opened by surgeon and is culture
positive or not cultured and fever >38 C, localized pain or tenderness
c. Abscess or other evidence of infection found on direct exam, during invasive
procedure, by histopathologic exam or imaging test
d. Diagnosis of deep SSI by surgeon or attending physician

5. ORGAN/SPACE SSI
• Infection occurs within 30 days after the operation if no implant is left in place or within 1 yr. if implant is in
place and the infection appears to be related to the operation.
• Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers that is opened or
manipulated during the operative procedure
• Patient has at least 1 of the following:
a. Purulent drainage from drain placed into the organ/space
b. Organism isolated from an aseptically-obtained culture of fluid or tissue in the organ/space
c. Abscess or other evidence of infection found on direct exam, during invasive procedure, or by histopathologic or
exam or imaging test
d. Diagnosis of an organ/space infection by a surgeon or attending physician

6. FURTHER CLASSIFICATION
Severity:
a) Minor
• discharge without cellulitis or deep tissue destruction
b) Major
• Pus discharge with tissue breakdown ,
• Partial or total dehiscence of the deep fascial layers of wound
• Systemic illness is present
 Time:
a) Early
• Infection presents within 30 days of procedure
b) Intermediate
• Occurs between one and three months
c) Late
• Presents more than three months after surgery

7. PATHOPHYSIOLOGY
• Micro-organisms are normally prevented from causing infection in tissues by:
• mechanical: intact epithelium
• chemical: low gastric pH;
• humoral: antibodies, complement and opsonins;
• cellular: phagocytic cells, macrophages, polymorphonuclear cells and killer lymphocytes.
……….may be compromised by any comorbid condition of the patient, surgical intervention and
treatment leading to SSI.

8. RISK FACTORS FOR DEVELOPING SSI
 Patient factor:
• Older age
• Immunosuppression
• Obesity
• Diabetes mellitus
• Chronic inflammatory process
• Malnutrition
• Peripheral vascular disease
• Smoking
• Anemia
• Radiation
• Steroid use

9. Local factor;
• Poor skin preparation
• Contamination of instruments
• Inadequate antibiotic prophylaxis
• Prolonged procedure
• Site and complexity of procedure
• Local tissue necrosis
• Hypoxia
• Hypothermia

10. Microbial factor:
• Wound Class
• Prolonged hospitalization (leading to nosocomial organisms)
• Resistance

11. WOUND CLASS

12. WOUND CLASS
 Clean wounds (class l) :
• Elective surgery excluding GIT,UT,RT.
 Clean contaminated (class ll):
• Elective surgery on GIT ,UT, RT
• NO SIGNIFICANT SPILLAGE
 Contaminated (class lll) :
• Open wounds (accident) within 4 hours
• Gross spillage from GIT,UT
 Dirty (class lV ) :
• Traumatic wounds more than 4 hours
• Perforated viscus
• Abscess /necrotizing fasciitis

13. MANAGEMENT OF SURGICAL SITE INFECTION
• Most SSIs respond to the removal of sutures with drainage of pus if present and,
occasionally, there is a need for debridement and open wound care.
• Incomplete sealing of the wound edges can often be managed by using a
delayed primary or secondary suture or closure with adhesive tape, but in larger
open wounds the granulation tissue must be healthy with a low bioburden of
colonizing or contaminating organisms if healing is to occur.

14. PREVENTION OF SSI
Pre-op factors
Intra-op factors
 Post-op factors

15. PRE-OP FACTORS
Preoperative antiseptic showering
o Preoperative hair removal
o Patient skin preparation in the operating room
oPreoperative hand/forearm antisepsis( Alcohol solution,
Chlorhexidine gluconate, Iodophors)
o Antimicrobial prophylaxis

16. PROPHYLACTIC ANTIBIOTICS
Clean wounds: no need for antibiotics except:
• Implant as mesh or vascular graft
• Valvular heart disease to prevent infective endocarditis
• In emergency situations as trauma
 Recommended dose: one dose 1st generation cephalosporin or (ampicillin +sulbactam)
Clean contaminated:
 One dose of 2nd generation of cephalosporin or (ampicillin +sulbactam) + Aminoglycoside
Contaminated:
 As above + Metronidazole

17. INTRA OPERATIVE FACTORS
• Operating room environment:
• Temperature: 68o-73oF, depending on normal ambient temp
• Relative humidity: 30%-60%
• Air movement: from “clean to less clean” areas
• Surgical attire and drapes
• Asepsis and surgical technique

18. POST OPERATIVE FACTORS
Incision care
• The type of postoperative incision care:
• closed primarily: the incision is usually covered with a sterile dressing for 24 to 48 hours.
• left open to be closed later: the incision is packed with a sterile dressing.
• left open to heal by second intention: packed with sterile moist gauze and covered with a sterile dressing.
Changing dressings
• Use an aseptic non-touch technique for changing or removing surgical wound dressings.
 Postoperative cleansing
• Use sterile saline for wound cleansing up to 48 hours after surgery.
• Advise patients that they may shower safely 48 hours after surgery.
• Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to
drain pus.
• Topical antimicrobial agents for wound healing by primary intention

19. SEVERE INFLAMMATORY RESPONSE SYNDROME AND
SEPSIS
SIRS
• Two of:
• hyperthermia (> 38°C) or hypothermia (< 36°C)
• tachycardia (> 90 /min, no β-blockers) or tachypnea (> 20 /min)
• white cell count > 12 × 109 / l or < 4 × 109 l
• Sepsis is SIRS with a documented infection
• Severe sepsis or sepsis syndrome or MODS is sepsis with evidence of one or more
organ failures [respiratory (acute respiratory distress syndrome), cardiovascular (septic shock follows compromise
of cardiac function and fall in peripheral vascular resistance), renal (usually acute tubular necrosis), hepatic, blood
coagulation systems or central nervous system]

20. MANAGEMENT
Initial evaluation and infection issues
• Initial resuscitation ( cvp :8-12 mm hg, MAP>65 mm hg and urine output>0.5 ml/kg/hr)
• Diagnosis ( via appropriate cultures)
• Antibiotic therapy
• Source control
• Hemodynamic support and adjunctive therapy :
• Fluid therapy
• Vasopressor/inotropic therapy ( MAP> 65) (nor epi and dopamine)
• Steroids
• Recombinant human activated protein c
• Blood product administration (if hb < 7 gm%)
• Mechanical ventilation
• Glucose control
• Prophylaxis ( stress ulcers and dvt)

21. SUMMARY
• SSI is an infected wound or deep organ space
• SIRS is the body’s systemic response to an infected wound
• MODS is the effect that the infection produces systemically
• MSOF is the end-stage of uncontrolled MODS
• MSOF ultimately leads to death.

22. Thank you.