SURGICAL SITE INFECTION

1. SURGICAL SITEINFECTION

2. WHAT ISSURGICAL SITE INFECTION?
• Asurgical site infection is an infection that occurs in thewound
created by an invasive surgical procedure.
• It leadsto
increased morbidity
increased mortality
Increased duration of hospital stay (7 dayson anaverage)
increased cost

3. Types ofSSI
• Superficial incisional SSI
• Deepincisional SSI
• Organ / spaceSSI

4. Superficial incisionalSSI
• Infection occurs within 30 daysafter surgicalprocedure
AND
• Involves only skin and subcutaneous tissue of theincision
AND
• Patient hasat least 1 of thefollowing:
• a. Purulent drainage from the superficialincision
• b. Organism isolated from an aseptically-obtained culture of fluid or tissue
• c. Superficial incision that is deliberately opened by a surgeon and is culture
positive or not cultured and patient has at least one of the following signs or
symptoms: pain or tenderness, localized swelling, redness,heat
• d. Diagnosisof superficial SSIby surgeon or attendingphysician

5. Do not report the following condition as SSI
• Stitch abscess(minimal inflammation and discharge confined to the
points of suturepenetration)
• Infection of an episiotomy or newborn circumcisionsite
• Infected burn wound
• Incisional SSIthat extends into the fascial and musclelayers.

6. Deep IncisionalSSI
• 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.
AND
• Involves deep soft tissues of the incision, e.g., fascial &muscle layers
AND
• Patient hasat least 1 of thefollowing:
a.Purulent drainage from deepincision
b. Deepincision spontaneously dehisces or opened by surgeon and isculture
positive or not cultured and fever >38 C,localized pain or tenderness (Note:a
culture negative finding does not meet thiscriterion)
c.Abscessor other evidence of infection found on direct exam, duringinvasive
procedure, by histopathologic exam or imagingtest
d. Diagnosis of deep SSIby surgeon or attendingphysician

7. Organ SpaceSSI
• 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.
AND
• Infection involves any part of the body, excluding the skin incision, fascia, or muscle layers
that is opened or manipulated during theoperative procedure
AND
• Patient hasat least 1 of thefollowing:
a.Purulent drainage from drain placed into theorgan/space
b. Organismisolated from an aseptically-obtained culture of fluid or tissue in the
organ/space
c.Abscessor other evidence of infection found on direct exam,during invasive
procedure, or by histopathologic or examor imagingtest
d. Diagnosisof an organ/space infection by asurgeon or attendingphysician

8. Furtherclassification
• Severity
a)Minor
discharge without cellulitis or deep tissuedestruction
b) Major
Pusdischarge with tissue breakdown ,
Partial or total dehiscence of thedeep fascial layers of
wound
Systemicillness is present.

9. a) Early
Infection presents within 30 daysof procedure
b) Intermediate
Occursbetween one and three months
c) Late
Presents more than three months aftersurgery

10. Pathophysiology
• Micro-organisms are normally prevented from causing infection intissues
by
• mechanical: intact epithelium
• chemical: low gastricpH;
• humoral: antibodies, complement and opsonins;
• cellular: phagocytic cells, macrophages, polymorphonuclear
cells and killer lymphocytes.
……….maybe compromised by any comorbid condition of the patient,
surgical intervention and treatment leading to SSI.

12. Risk factors for developingSSI
• Patient factor
• Local factor
• Microbial factor

13. Patientfactor
• Older age
• Immunosuppression
• Obesity
• Diabetes mellitus
• Chronic inflammatory process
• Malnutrition
• Peripheral vasculardisease
• Smoking
• Anaemia
• Radiation
• Steroid use

14. Localfactor
• Poor skin preparation
• Contamination of instruments
• Inadequate antibiotic prophylaxis
• Prolonged procedure
• Site and complexity of procedure
• Localtissue necrosis
• Hypoxia
• Hypothermia

15. Microbialfactor
• Wound Class
• Prolonged hospitalization (leading to nosocomialorganisms)
• Resistance

16. WoundClass

17. Common pathogen in surgicalpatients

18. Wound assessment
• ASEPSIS
• SOUTHAMPTON
• enable surgical wound healing to
be graded according to specific
criteria, usually giving a
numerical value, thus providing
more objective assessmentof
wound

19. ASEPSISwound
scoringsystem

20. • Score0-10-satisfactory healing
• 11-20-disturbance of healing
• 20-30-minor wound infection
• 31-40-moderate wound infection
• >41-severe wound infection

21. Southampton
scoringsystem

22. SENIC Risk Index (the study of the effectof nosocomial infectioncontrol)
• Abdominal operation
• Operation greater than
2 hours
• ClassIII or IVsurgical
wounds
• Three or more
diagnosis at time of
discharge
Riskof Infection
0 1%
1 3.6%
2 9%
3 17%
4 27%

23. Management of surgical siteinfection
• Most SSIsrespond to the removal of sutures with drainage of pus if present
and, occasionally, there is aneed for debridement and open wound care.
• Incomplete sealing of the wound edgescanoften 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 alowbio-
burden of colonizing or contaminating organisms if healing is to occur.

24. Prevention ofSSI
• Pre-op factors
• Intra-op factors
• Post-op factors

25. Pre-opfactors
• Preoperative antiseptic showering
• Preoperative hair removal
• Patient skin preparation in the operatingroom
• Preoperative hand/forearm antisepsis( Alcohol solution, Chlorhexidine
gluconate, Iodophors)
• Antimicrobial prophylaxis

26. Antibioticprophylaxis
• Giveantibiotic prophylaxis to patientsbefore:
• clean surgery involving the placement of aprosthesisor
implant
• clean-contaminated surgery
• contaminated surgery.
Do not use antibiotic prophylaxis routinely forcleannon-prosthetic
uncomplicated surgery.
•Consider giving asingle dose of antibiotic prophylaxis intravenously on
starting anaesthesia.

27. Wound
Classification
Antibiotic Penicillin Allergy
I
1st generation
Cephalospori
n
Vancomycin Clindamycin
II-Biliary,GU, Upper
Digestive
1st generation
Cephalospori
n
Vancomycin Clindamycin
II-Distal Digestive
2nd generation
Cephalospori
n
Aztreonam and
Clindamycin/metronidazole
III/IV Generally Therapeutic

29. Point toremember
Oncethe
incision ismade,
antibiotic
delivery to the
wound is
impaired. Hence
must given
before incision!

30. Intra operativefactors
• Operating room environment
Temperature: 68o-73oF, depending on normal ambient temp
Relative humidity: 30%-60%
Air movement: from “clean to lessclean”areas
• Surgical attire anddrapes
• Asepsisand surgical technique

31. Post operativefactors
• Incision care
Thetype of postoperative incision care
@closed primarily: the incision is usually covered with asterile dressingfor
24 to 48hours.
@left open to be closed later: the incision is packed with asterile dressing.
@left open to heal by second intention: packed withsterile moist gauzeand
covered with asterile dressing.

32. • Changing dressings
Usean aseptic non-touch technique for changing orremoving
surgical wound dressings.
• Postoperative cleansing
•Usesterile saline for wound cleansing up to 48 hours after surgery.
• Advisepatients that they may shower safely 48 hours after surgery.
•Usetap water for wound cleansing after 48 hours if the surgical
wound hasseparated or hasbeen surgically opened todrain pus.
•Topicalantimicrobial agents for wound healing by primaryintention

33. Severe inflammatory response syndromeand
sepsis
SIRS
Twoof:
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 ×109l
• Sepsisis SIRSwith adocumented infection
• Severesepsisor sepsissyndrome or MODSis sepsiswith 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 coagulationsystems
or central nervoussystem]

34. Survivingsepsis
• Initial evaluation and infectionissues
• Initial resuscitation ( cvp :8-12 mm hg, MAP>65 mm hg and urineoutput>0.5
ml/kg/hr)
• Diagnosis ( via appropriatecultures)
• Antibiotic therapy ( BSAbat the beginning thenorganism specific)
• Source control
• Hemodynamic support and adjunctivetherapy
• Fluid therapy
• Vasopressor/inotropic therapy ( MAP>65) (nor epi anddopamine)
• Steroids
• Recombinant human activated protein c(in adults withsepsisinduced organ
dysfunction)

35. • Other supportive therapy
• Blood product administration (if hb <7gm%)
• Mechanical ventilation(TV- 6 ml/kg, PEEP-toavoid collapse andpleateu
pressure <30 mm hg)
• Glucosecontrol
• Prophyllaxis ( stress ulcers anddvt)

36. Tosum itup
• SSIis an infected wound or deep organspace
• SIRSis the body’s systemic response to an infectedwound
• MODSis the effect that the infection producessystemically
• MSOFis the end-stage of uncontrolledMODS
• MSOFultimately leads todeath.

37. Thank you.