Surgical Site Infections

SURGICAL SITE
INFECTIONS
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
POGS Cebu chapter
April 11, 2019

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

The human and financial costs of treating surgical site infections
(SSIs) are increasing. The number of surgical procedures performed
in the US continues to rise, and surgical patients are initially seen
with increasingly complex comorbidities. It is estimated that
approximately half of SSIs are deemed preventable using evidence-
based strategies.

Factors that increase the cost and challenge of treating SSIs
1. Surgical patients initially seen with more complex comorbidities
2. Emergence of antimicrobial-resistant pathogens

Burden of SSIs Worldwide
SSI is both the most frequently
studied and the leading HAI reported
hospital-wide in LMICs. For these
reasons, the prevention of SSI has
received considerable attention from
surgeons and infection control
professionals, health care authorities,
the media and the public. In
particular, there is a perception
among the public that SSIs may
reflect a poor quality of care.

Pelvic Surgical Site Infections
in Gynecologic Surgery
SSIs are infections occurring within 30
days of an operation occurring in one of
three locations:
•superficial at the incision site
•deep at the incision site
•in other organs or spaces opened or
manipulated during an operation
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

involves only the skin
or subcutaneous tissue

involves the fascia or
muscular layers

involves any part of the
body opened or
manipulated during a
procedure, excluding the
previously mentioned
layers

RISK FACTORS FOR SSI
•Pre-operative Risk
Factors
•Peri-operative and
Intra-operative Risk
Factors
•Post-operative Risk
Factors
Asia Pacific Society for Infection Control. The APSIC Guidelines for Prevention of Surgical Site Infections 2018

INTRINSIC (PATIENT) FACTORS
• NON-MODIFIABLE – increased age, recent
radiotherapy, history of skin or soft tissue infection
• MODIFIABLE
• Diabetes
• Obesity
• Alcoholism
• Current smoker
• Preoperative albumin <3.5 mg/dL
• Total bilirubin >1.0 mg/dL
• immunosuppression
American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update

EXTRINSIC (PROCEDURE-RELATED)
FACTORS
• PROCEDURE – emergency, increasing complexity,
higher wound classification
• FACILITY – inadequate ventilation, increasing operating
room traffic, contaminated environmental surfaces,
non-sterile equipment
• PREOPERATIVE – pre-existing infection, inadequate
skin preparation, inappropriate antibiotic choice,
timing, and weight-based dosing, hair-removal
method, poor glycemic control

EXTRINSIC (PROCEDURE-RELATED)
FACTORS
•INTRAOPERATIVE
• Longer procedure duration
• Blood transfusion
• Breach in asepsis
• Inappropriate antibiotic re-dosing
• Inadequate gloving
• Inappropriate surgical scrub
• Poor glycemic control

• Philippine College of Surgeons
• Philippine Hospital Infection Control Society
• Philippine Hospital Infection Control Nurses Association
• Operating Room Nurses Association of the Philippines, Inc

Philippine Journal of Surgical Specialties. Consensus Recommendations on the Prevention and Management of Surgical Site Infections (SSI) in the Philippine Setting 2017
36 salient recommendations on the prevention and management of SSIs

Recommendation #1:
Maintaining normal body temperature
• Use of warming devices
pre-operatively and
intra-operatively for the
purpose of maintaining
normothermia is
recommended

Recommendation #2:
Smoking cessation
• Smoking cessation is
recommended for
patients within 30 days
of surgery or within 4-6
weeks for procedures
involving implanted
devices

Recommendation #3:
Nutritional Support
• Nutritional status must be
optimized prior to major
surgery
• Delaying surgeries to
administer parenteral
nutrition is not
recommended due to lack
of evidence demonstrating
reduced SSI risk

Recommendation #4:
Glucose Control
• Adoption of protocols for
perioperative blood glucose levels
recommended to be performed in
patients with hyperglycemia with or
without diabetes, patients with
stroke, critically ill patients who
have suffered myocardial infarction,
and patients who had a major
cardiac surgery

Recommendation #5:
Maintaining adequate circulating
volume
• Hemodynamic goal-directed
therapy is recommended for
decreasing SSI risk
• Blood transfusion should be
avoided as much as possible since
it is associated with impairment of
the function of macrophages,
which can lead to increased SSI
risk

Recommendation #6:
Supplemental
oxygen/hemoglobin
saturation
• To improve oxygenation status, supplemental oxygen
should be provided together with maintenance of
normothermia and adequate circulating blood
volume
• Maintain target hemoglobin saturation of at least
95% intraoperatively and post-operatively

Recommendation #7:
Systemic immunosuppressive therapy
• Conflicting recommendations
on the discontinuation of
immunosuppressive
medications for the reduction
of SSI risk

Recommendation #8:
MRSA Screening and decolonization
• Routine perioperative MRSA
screening and decolonization is
not recommended because of
absence of standardized
screening procedure and
decolonization protocol
• Recommended for high risk
patients
mupirocin 2%
ointment

MRSA Screening and decolonization
• Patients previously admitted to a hospital
• Patients with chronic wounds or skin lesions
• Patients transferred from a nursing home or long-term
care facility to the hospital
• Patients on hemodialysis
• Patients using urinary or intravenous catheters
• Patients undergoing cardiothoracic surgery
• Orthopedic surgery
• Procedures involving implants
• Elderly diabetic patients

Recommendation #9:
Bowel preparation
• Mechanical bowel preparation in combination with
oral and parenteral antibiotic prophylaxis is
recommended to reduce SS risk in patients
undergoing elective colorectal surgeries.

Recommendation #10:
Preoperative bathing or showering
• Preoperative bathing or
showering is
recommended
• Patient may opt to take a
bath or shower inside or
outside of the healthcare
facility using either plain
soap or anti-microbial
soap

Recommendation #11:
Hair removal
• Hair removal prior to surgery is not recommended
except when absolutely necessary
• When needed, hair removal should be done using
clippers because of associated lower SSI rates
• Use of razors is not recommended due to increased
SSI risk
• Hair removal should not be performed inside the
operating room

Recommendation #12:
Surgical hand
decontamination and
preparation
• Hand decontamination using an appropriate
antimicrobial agent and water or an alcohol-based
hand rub that can withstand the growth of resident
flora for long periods of time is recommended
before wearing sterile gloves
• Scrubbing of the forearms and hands for 2-5
minutes is recommended

Recommendation #13:
Skin preparation
• Use of alcohol-based antiseptic agent in skin
preparation is recommended except when there are
contraindications for its use. Then, povidone-iodine
is recommended antiseptic agent
• In the absence of alcohol and contraindications,
chlorhexidine is preferred over iodine.

Recommendation #14:
Surgical antibiotic prophylaxis (SAP)
• SAP should be administered only when indicated and is
usually based on the following
1. Existing national or local guidelines or formulary
2. Existing clinical practice guidelines or evidence-based
guidelines and standards
3. Type of surgical procedure
4. The identified SSI-causing pathogen for a procedure

Recommendation #14:
• Timing of administration and dosing:
SAP should be administered within
60 minutes prior to incision to
ensure serum and tissue
concentration with bactericidal
effect at time of incision

Recommendation #14:
Surgical antibiotic
prophylaxis (SAP)
• Re-dosing of antibiotic – intraoperative re-dosing of
prophylactic antibiotic is recommended if
1. Excessive blood loss (i.e. greater than or equal to
1,500 mL for adults) or 25 mL/kg in children
2. For prolonged procedures
3. If the duration of the procedure exceeds the half-
life of the antibiotic

Recommendation #14:
• Prolongation of surgical antibiotic prophylaxis –
continuing administration of SAP after incision
closure in the operating room for clean and clean-
contaminated procedures or even in the presence of
wound drain is not recommended due to the lack of
evidence linking it with reduction of SSI risk and the
increased risk of antibiotic resistance and
Clostridium difficile infections.

Recommendation #14:
• Topical/local antibiotics – use of topical antibiotics is
generally not recommended except for such
procedures as ophthalmic surgery, spine surgery,
and total joint arthroplasty.

Recommendation #15:
Soaking prosthetic devices in
antimicrobial solutions before
implantation
• No specific recommendation due to lack of evidence
associated with reduction in SSI risk

Recommendation #16:
wound irrigation / wound lavage /
intra-cavitary lavage
• No specific recommendation regarding incisional
wound irrigation with saline solution due to lack of
evidence linking it with reduction in SSI risk
• Incisional wound irrigation with antibiotics is not
recommended for the purpose of reducing SSI risk

Recommendation #16:
wound irrigation/wound lavage/intra-
cavitary lavage
• Antimicrobial irrigation of deep, subcutaneous or
intra-abdominal tissues is not prescribed since its
effect on reducing SSI risk remains unestablished
• Antiseptic wound lavage, intra-cavitary lavage and
intra-peritoneal lavage is generally not
recommended

Recommendation #17:
intraoperative re-disinfection before
wound closure
• No specific recommendation on intra-operative re-
disinfection before wound closure due to lack of
evidence associated with reduction in SSI risk

Recommendation #18:
Wound care
Wound closure
• No specific recommendation on
the best type of wound closure for
dirty and contaminated surgical
incisions
• Lack of evidence on which
between primary closure and
delayed primary closure is more
effective in reducing SSI risk

Recommendation #18:
Wound care
Antibacterial/antiseptic
sutures
• Use of triclosan-coated
sutures is recommended to
decrease risk of SSI for all
types of surgeries,
especially for clean and
clean-contaminated
abdominal cases

Recommendation #18:
Wound care
Dressings
• Application of appropriate interactive dressing and
sterile wound dressing on surgical incision sites at
the end of the procedure is recommended
• Standard dressing is preferred over advanced
dressing to cover primarily closed incisional wounds

Recommendation #18:
Wound care
Topical antimicrobial healing by primary intention
• Use of topical antimicrobial agents for surgical
wound healing by primary intention to prevent SSI is
not recommended

Recommendation #18:
Wound care
Wound probing, wound cleansing and changing
• It is recommended to keep the dressing intact
without tampering or removal for 48 hours post-
operatively, unless it is grossly contaminated
• Use of aseptic, no-touch technique is recommended
to prevent the transfer of microbes from the
environment to the surgical wound
• Handwashing required before and after removing an
changing dressings, and probing wounds

Recommendation #19:
antibiotic treatment of surgical site
infection
• Administration of an antibiotic that targets the
causative pathogen is recommended
• Microbiological test results and local resistance
patterns must be considered when making a
decision on the specific antibiotic to use

Recommendation #20:
drapes and gowns/patient theater
wear/surgical attire/staff theater wear
• Sterile disposable non-woven, or sterile
reusable woven drapes and gowns are
recommended as surgical attire
• During surgery, the operating team
should wear sterile gowns
• Patient’s wear should consider comfort
and appropriate concealment

Recommendation #21:
incise drapes
• Use of plastic adhesive incise
drapes with or without
antimicrobial properties,
routine use of antiseptic incise
drapes, and routine use of non-
iodophor-impregnated incise
drapes for the reduction of SSI
risk is not recommended.

Recommendation #22:
facility scrub laundering
• Facility scrub laundering is recommended

Recommendation #23:
antimicrobial skin sealants
• Application of antimicrobial
skin sealants after surgical site
preparation is not
recommended because of low-
to very low-quality evidence
linking it with reduced SSI risk.

Recommendation #24:
use of mask
• Use of surgical mask is
recommended, not only
to prevent SSI, but also
for the protection of the
health care worker

Recommendation #25:
gloves
• No-touch technique is recommended
• Double gloving should be considered if there is high
risk of glove perforation, or if contamination may
lead to grave outcomes
• No specific recommendations on changing of gloves
during surgery and on the type of gloves most
effective in preventing SSI due to paucity of high
quality evidence

Recommendation #26:
jewelry, artificial nails, and nail polish
• Patients should remove all jewelry, artificial nails,
and nail polish before surgery

Recommendation #27:
changing of surgical instruments
• No specific
recommendation on
changing of surgical
instruments for fascial,
subcutaneous, and skin
surgical incision closure
due to insufficient data
linking this practice with SSI
rates

Recommendation #28:
surgical skill/technique
• Delicate tissue handling and the removal of dead
space are recommended

Recommendation #29:
operative time
• Operative time must be kept to a minimum, while
ensuring surgical and aseptic techniques are not
compromised.

Recommendation #30:
ventilation in the operating room
• Proper air handling and laminar air flow in the
operating room is recommended
• Air-conditioning machines are recommended to be
used for this purpose
• Fans are not recommended unless as last resort
• All fans and air-conditioning machines in the
operating room should be routinely cleaned

Recommendation #31:
environmental surfaces
• For surfaces and equipment that are visibly soiled or
contaminated, cleaning them with approved
disinfectants is recommended

Recommendation #32:
sterilization of surgical equipment
• Limited use of immediate-use
steam sterilization equipment
such as flash autoclaves is
recommended

Recommendation #33:
traffic
• Traffic in the operating room should be kept to a
minimum

Recommendation #34:
information for patients and
caregivers
• Educating patients and their caregivers on SSI is
recommended

Recommendation #34:
information for patients and
caregivers
1. Risks of SSIs
2. Strategies to prevent SSIs
3. Management of SSIs
4. Caring for surgical incision wounds post-discharge
5. Recognizing SSI
6. The person to contact for the patient’s or the
caregiver’s concerns

Recommendation #35:
information for surgeons and
perioperative personnel
• Healthcare personnel involved in difference
perioperative phases should be provided with
information regarding SSI

Recommendation #35:
information for surgeons and
perioperative personnel
1. SSI risk factors
2. SSI outcomes
3. Local epidemiology (e.g. SSI rates by procedure,
rate of MRSA infection in a facility)
4. Basic prevention strategies

Recommendation #36:
Use of WHO checklist
• Use of WHO safety
checklist is
recommended to
ensure that best
practices in patient
safety are adhered to

Vaginal cuff cellulitis
Moderate, but increasing, lower abdominal pain
with purulent yellow vaginal discharge
• Amoxicillin/clavulanate 875/125 mg po bid
• Ciprofloxacin 500 mg po bid + metronidazole 500 mg bid
• TMP-SMX DS po bid + metronidazole 500 mg po bid

Pelvic cellulitis and abscess
Pelvic cellulitis and pelvic hematoma spread into
parametrial soft tissue: fever, vague abdominal
pain, regional tenderness, mass
• clindamycin 900 mg IV q8h OR metronidazole 500 mg IV q12h +
• penicillin 5 million units q6h OR ampicillin 2 g IV q6h +
• gentamicin 5 mg/kg body weight q24h OR aztreonam 2 g IV q8h

DRAINAGE OR SURGICAL THERAPY
• Routine drainage of pelvic abscesses can decrease
prolonged hospitalizations and improve
reproductive outcomes.

DRAINAGE OR SURGICAL THERAPY
• Drainage should be performed if an adequate
response to antibiotic therapy is not registered
within 2-3 days or if the pelvic abscess is >8cm

Criteria for failure
• patients with <50% radiological reduction in abscess
size
• patients whose abscess progressively increased in size
• new onset fever or persistent fever
• clinical deterioration with persistent or worsening
abdominal / pelvic tenderness despite appropriate
antibiotic therapy
• sepsis
• ruptured abscess

Women with abscesses >8cm
or who show no signs of improvement
• Clinically worsening patients, suspected
rupture, and septic patients require immediate
laparotomy which may be life-saving.
• Laparoscopy has several advantages compared
to laparotomy, if the patient is hemo-
dynamically stable.

Drainage
• Percutaneous drainage guided by CT or
ultrasound even with large abscesses
• No required anesthesia
• Immediate pain relief
• Reduced duration of hospital stay
• Pelvic cuff abscess by ultrasound guided
transvaginal aspiration

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Surgical Site Infections

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