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Surgical Site Infection
Introduction
Ignaz Semmelweis and Joseph Lister became the pioneers of infection control by introducing antiseptic surgery in middle of 19th century.
Since then a number of significant developments, particularly in the field of microbiology, have made surgery safer
In 1992, the US Centers for Disease Control (CDC) revised its definition of 'wound infection', creating the definition 'surgical site infection' (SSI) to prevent confusion between the infection of a surgical incision and the infection of a traumatic wound
Classification
Incisional organ, or other organs and spaces manipulated
during an operation
Incisional infections are further classified into-
superficial (skin and subcutaneous tissue) and
deep (deep soft tissue-muscle and fascia)
Microbiology of Surgical Site Infections In clean surgical procedures, in which the
gastrointestinal, gynecologic, and respiratory tracts have not been entered, Staphylococcus aureus from the exogenous environment or the patient’s skin flora is the usual cause of infection
Factors influencing SSIs (Lancet2000) Surgical considerations Skin preparation Site, duration and complexity of the surgery. Presence of suture or foreign body Suturing quality. Pre-existing local or systemic infection Prophylactic atibiotic Haematoma Mechanical stress on wound
Anesthetic considerations
Tissue perfusion Normovolaemia or hypovolaemia Concentration of the inspired oxygen Perioperative body temperature Pain Blood transfusion
Patient related factors Diabetes Alcoholism Smoking Poor nutrition Jaundice Obesity Advanced age Poor physical condition
Surgical Factors- Decreased collagen synthesis
Anesthetic factors- Vasoconstriction
Patient factors -Immunosuppression
Decreased tissue perfusion
Decreased PtO2
Decreased collagen Decreased neutrophil Deposition Bactericidal activity Decreased wound Increased wound tensile strength Infection
Wound break down
Classification for operative wounds
Clean- Elective, not emergency, non-traumatic, primarily closed; no acute inflammation; no break in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered.
Clean contaminated- Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy)
Contaminated- Non-purulent inflammation; gross spillage from gastrointestinal tract; entry into biliary or genitourinary tract in the presence of infected bile or urine; major break in technique; penetrating trauma <4 hours old; chronic open wounds to be grafted or covered.
Dirty- Purulent inflammation (e.g. abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetrating trauma >4 hours old. (Ann Surgery 1964)
Rates of Infection
clean 2.1%, clean-contaminated 3.3%, contaminated 6.4% and dirty 7.1%
US National Nosocomial Infection Surveillance (NNIS) system
Prevention of SSI
Appropriate use of antibiotics; Appropriate hair removal; Maintenance of postoperative glucose
control Maintenance of postoperative
normothermia
Antibiotics
One dose of antibiotic to be given preoperatively
It is generally recommended in elective clean surgical procedures and clean contaminated procedures that a single dose of cephalosporin to be administered intravenously
Involve pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration of antibiotic
Hair removal
Hairs to be removed in OT just before surgery.
Use of clippers than razors reduces the chances of infection
Glucose control
Implement a glucose control protocol. Develop one protocol to be used for all
surgical patients. Regularly check preoperative blood glucose
levels on all patients to identify hyperglycemia;
Assign responsibility and accountability for blood glucose monitoring and control.
CDC surgical site infections prevention guidelines, 1999 Category 1A- Strongly recommended for
implementation and supported by well-designed experimental, clinical, or epidemiologic studies
Treat remote infection before elective operation;
Postpone surgery until treated;
Do not remove hair from operative site unless necessary to facilitate surgery; If hair is removed, do immediately before surgery, preferably with electric clippers
Select an antimicrobial agent with efficacy against expected pathogen;
Intravenous route used to ascertain adequate serum levels during operation and for at most a few hours after incision closed
Category 1B- Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and strong theoretical rationale
Control serum blood glucose perioperatively; Cessation of tobacco use 30 days before
surgery; Do not withhold necessary blood products to
prevent SSIs
Shower or bath on night before operative procedure;
Wash incision site before performing antiseptic skin preparation with approved agent
Do not routinely use vancomycin for antimicrobial prophylaxis
Category II- Suggested for implementation and supported by suggestive clinical or epidemiologic studies or theoretical rationale
Prepare skin in concentric circles from incision site;
Keep preoperative stay in hospital as short as possible
Superficial incisional surgical site infections
occur within 30 days of procedure involve only the skin or subcutaneous tissue
around the incision.
purulent drainage from the incision organisms isolated from an aseptically
obtained culture of fluid or tissue from the incision
at least one of the following signs or symptoms of infection - pain or tenderness, localised swelling, redness or heat - and the incision is deliberately opened by a surgeon, unless the culture is negative
Don’t considered superficial SSIs stitch abscesses infection of an episiotomy or neonatal
circumcision site infected burn wounds incisional SSIs that extend into the fascial
and muscle layers
Deep incisional surgical site infections occur within 30 days of procedure (or one
year in the case of implants) are related to the procedure involve deep soft tissues, such as the
fascia and muscles.
purulent drainage from the incision but not from the organ/space of the surgical site
a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms - fever (>38°C), localised pain or tenderness - unless the culture is negative
an abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiological examination
(CDC definitions of surgical wound infections )
Wound assessment
ASEPSIS –to assess wounds resulting from cardiothoracic surgery
Southampton Wound Assessment Scale –
categorized according to any complications and their extent
ASEPSIS wound scoring system
Score 0-10-satisfactory healing 11-20-disturbance of healing 20-30-minor wound infection 31-40-moderate wound infection >41-severe wound infection
Southampton scoring system Grade Appearance
0 Normal
I Normal healing with mild bruises and erythema
A Some bruising B considerable brusing C Mild erythema
Grade Appearance II Erythema plus other signs
of infection A At one point B Around sutures C Along wound D Around wound
Grade Appearance III Clean or haemoserous
discharge A At one point only B Along wound C Large volume D Prolonged
Grade Appearance IV Major wound
complication like pus A At one point only B Along wound
V Deep or severe
infection with or without
breakdown
Treatment
Surgical debridement of wound and antibiotics according to sensitivity
Thank you