Surgical Site Infection

PPT MADE BY: DR RAJESH T EAPEN ATLAS HOSPITAL MUSCAT

What is a Surgical Site Infection (SSI)?

A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. SSIs are one of the most important causes of healthcare-associated infections (HCAIs).

Outcomes

Increase morbidity

Increase mortality

Increase length of stay

Increase cost

Three levels of SSI: • superficial incisional, affecting the skin

and subcutaneous tissue- may be

indicated by localized signs such as

redness, pain, heat or swelling at the site of

the incision or by the drainage of pus.

• deep incisional, affecting the fascial and

muscle layers- indicated by the presence

of pus or an abscess, fever with tenderness

of the wound, or a separation of the edges

of the incision exposing the deeper tissues.

Levels of SSI…contd….

• organ or space infection- which involves any

part of the anatomy other than the incision that

is opened or manipulated during the surgical

procedure, for example joint or peritoneum.

Cross Section of Abdominal Wall Depicting SSI Classification

Symptoms of a surgical site

infection include:

A delay in healing of the surgical site

The tissue around the surgical site may be

discolored

A foul odor coming from the incision site

Pain or sever tenderness in the area of the

incision

Severe swelling of the incision

Incision is hot to the touch

Doctor should be notified at the earliest sign

of symptoms.

Wound discharge with no other complications

Life-threatening condition

Other clinical outcomes of SSIs • poor scars that are cosmetically unacceptable, (spreading,

hypertrophic or keloid, persistent pain and itching, restriction of movement, particularly when over joints)

Pathogenesis of surgical site infection The development of an SSI depends on contamination of the wound site at the end of a surgical procedure and specifically relates to the pathogenicity and inoculum of microorganisms present, balanced against the host’s immune response.

Microorganisms that cause SSIs are usually derived from the patient (endogenous infection), being present on their skin or from an opened viscus.

Exogenous infection occurs when microorganisms from instruments or the theatre environment contaminate the site at operation, when microorganisms from the environment contaminate a traumatic wound, or when microorganisms gain access to the wound after surgery, before the skin has sealed.

SSI Risk Factors

• Age

• Obesity

• Diabetes

• Malnutrition

• Prolonged preoperative

stay

• Infection at remote site

• Systemic steroid use

• Nicotine use

• Hair removal/Shaving

• Duration of surgery

• Surgical technique

• Presence of drains

• Inappropriate use of

antimicrobial

prophylaxis

Surgical Technique

• Removing devitalized tissue

• Maintaining effective hemostasis

• Gently handling tissues

• Eradicating dead space

• Avoiding inadvertent entries into a

viscus

• Using drains and suture material

appropriately

Parameters for Operating

Room Ventilation*

• Temperature: 68o-73oF, depending on

normal ambient temp

• Relative humidity: 30%-60%

• Air movement: from “clean to less clean”

areas

• Air changes: >15 total per hour

>3 outdoor air per hour

*American Institute of Architects, 1996

Practices to prevent SSI are therefore aimed at : • minimising the number of microorganisms introduced

into the operative site • removing microorganisms that normally colonise the skin • preventing the multiplication of microorganisms at the operative site, for example by using prophylactic antimicrobial therapy • enhancing the patient’s defenses against infection, for example by minimising tissue damage and maintaining normothermia • preventing access of microorganisms into the incision postoperatively by use of wound dressings.

Staphylococcus aureus is the microorganism most commonly cultured from SSIs.

Operations on sites that are normally sterile (‘clean’) thus have relatively low rates of SSI (generally less than 2%), whereas after operations in ‘contaminated’ or ‘dirty’ sites, rates may exceed 10%.

Obesity :Adipose tissue is poorly vascularized and is thought to increase the risk of SSI.

Smoking: The wound healing process may be affected by the vaso-constrictive effects and reduced oxygen-carrying capacity of blood associated with smoking cigarettes. Smoking, duration of smoking and number of cigarettes smoked are associated with an increased risk of SSI

Other factors for risk of 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.

Many complications of postoperative wounds do not represent infection but exudation of tissue fluid or an early failure to heal, which is common in patients with a high body mass index (BMI).

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 bio-burden of colonizing or contaminating organisms if healing is to occur.

Management of surgical site infection

Preoperative showering Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap, either the day before, or on the day of, surgery. Hair removal • Do not use hair removal routinely to reduce the

risk of surgical site infection. • If hair has to be removed, use electric clippers

with a single-use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection.

Preoperative phase

Preoperative phase…contd.

Patient theatre wear • Give patients specific theatre wear that is

appropriate for the procedure and clinical setting and that provides easy access to the operative site and areas for placing devices, such as intravenous cannulas.

• Consider also the patient’s comfort and dignity.

Staff theatre wear • All staff should wear specific non-sterile

theatre wear in all areas where operations are undertaken.

Staff leaving the operating area • Staff wearing non-sterile theatre wear

should keep their movements in and out of the operating area to a minimum.

Hand jewellery, artificial nails and nail polish • The operating team should remove hand

jewellery before operations. • The operating team should remove

artificial nails and nail polish before operations.

Preoperative phase…contd.

Antibiotic prophylaxis Give antibiotic prophylaxis to patients before: • clean surgery involving the placement of a prosthesis or implant • clean-contaminated surgery • contaminated surgery. Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery. • Use the local antibiotic formulary and always

consider potential adverse effects when choosing specific antibiotics for prophylaxis.

• Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia.

Antibiotic prophylaxis

Give prophylaxis earlier for operations in which a tourniquet is used.

Before giving antibiotic prophylaxis, consider the timing and pharmacokinetics (for example, the serum half-life) and necessary infusion time of the antibiotic. Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.

Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.

Inform patients before the operation if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation

Intraoperative phase Hand decontamination • The operating team should wash their hands prior to

the first operation on the list using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails, and ensure that hands and nails are visibly clean.

• Before subsequent operations, hands should be washed using either an alcoholic hand rub or an antiseptic surgical solution. If hands are soiled then they should be washed again with an antiseptic surgical solution.

Use of sterile gowns The operating team should wear sterile gowns in the operating theatre during the operation. Gloves Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation and the consequences of contamination may be serious. Incise drapes • Do not use non-iodophor-impregnated incise drapes

routinely for surgery as they may increase the risk of surgical site infection.

• If an incise drape is required, use an iodophor-impregnated drape unless the patient has an iodine allergy.

Antiseptic skin preparation Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine are most suitable. Diathermy • If diathermy is to be used, ensure that antiseptic skin

preparations are dried by evaporation and pooling of alcohol-based preparations is avoided.

• Do not use diathermy for surgical incision to reduce the risk of surgical site infection.

Maintaining patient homeostasis • Maintain patient temperature • Maintain optimal oxygenation during surgery. In

particular, give patients sufficient oxygen during major surgery and in the recovery period to ensure that a haemoglobin saturation of more than 95% is maintained.

• Maintain adequate perfusion during surgery Blood Glucose control Do not give insulin routinely to patients who do not have diabetes to optimise blood glucose postoperatively as a means of reducing the risk of surgical site infection.

Wound irrigation and intracavity lavage • Do not use wound irrigation to reduce the risk of

surgical site infection. • Do not use intra-cavity lavage to reduce the risk of

surgical site infection. • Antiseptic and antimicrobial agents before wound

closure • Do not use intraoperative skin re-disinfection or

topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.

Wound dressings • Cover surgical incisions with an appropriate

interactive dressing at the end of the operation.

Postoperative phase 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

Postoperative cleansing

• Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection.

• Dressings for wound healing by secondary intention

• Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage surgical wounds that are healing by secondary intention.

Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary intention.

Antibiotic treatment of surgical site infection and treatment failure • When surgical site infection is suspected (i.e.

cellulitis), give the patient an antibiotic that covers the likely causative organisms.

• Consider local resistance patterns and the results of microbiological tests in choosing an antibiotic.

Debridement Do not use Eusol and gauze for debridement in the management of surgical site infection.

PREVENTION

IS PRIMARY! Protect patients…protect healthcare personnel…

promote quality healthcare!

YES WE CAN !!