Surgical site infections - Diagnosis, treatment and Prevention guidelines
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Transcript of Surgical site infections - Diagnosis, treatment and Prevention guidelines
Surgical Site Infections
Dr. Rahul AgarwalDNB General Surgery
Care Hospital
Why this topic?SSI is MOST COMMON hospital acquired infection in surgical patients.
3rd most common hospital acquired infection.
Preventable
Prolong the hospital stay (7.3 days)
Expenditure
Over one-third of postoperative deaths
Poor scar, persistent pain and itching, restriction of movement and a significant impact on emotional wellbeing
What is SSI?
Infections that occur in the wound created by an invasive
surgical procedure are generally referred to as surgical
site infections
Criteria for defining SSIs
Superficial incisional surgical site infections
Infection occur within 30 days of procedure
Involve skin or subcutaneous tissue • signs or symptoms of infection• purulent drainage +/-• organisms isolated• Diagnosis by experience
Stitch abscess, episiotomy, circumcision in infant, burn wound
Deep incisional surgical site infections
Infection occur within 30 days of procedure (or one year in the case of implants)
Involve deep soft tissues, such as the fascia and muscles.
• purulent drainage, signs of infection• spontaneously dehisces or opened by surgeon• an abscess or other evidence of infection
Involving both superficial and deep = DISSI
Space or organ ssi drain through Deep incision = DISSI
Organ or space Surgical site Infection
30 days no implant or 1 year with implant
Any part is involved which was opened or manipulated other than the incision• Purulent discharge from a drain• Isolated an organism• Abscess or other evidence of infection• Diagnosis by a surgeon
Early
• Infection presents within 30 days of procedure
Intermediate
• Occurs between one and three months
Late
• Presents more than three months after surgery
Minor• Wound infection is
described as minor when there is discharge without cellulitis or deep tissue destruction
Major
• When there is pus discharge with tissue breakdown , Partial or total dehiscence of the deep fascial layers of wound or if systemic illness is present.
Severity
Pathogenesis of surgical site infection
Contamination• Endogenous
infection• Exogenous
infection• Haematogenou
s spread• Staph aureus• Enterobacteri
aceae and anaerobes
Proliferation of bacteria
Induce inflammation –
signs appear
Identified or unidentified
Self resolving -> resolve by treatment ->
sepsis and death
Wound Assessment
ASEPSIS
• to assess wounds
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 bruising C Mild erythema
Grade Appearance• II Erythema plus other signs of infection
A At one point B Around suturesC Along woundD Around wound
Grade Appearance• III Clean or haemoserous discharge
A At one point onlyB Along woundC Large volumeD Prolonged
Grade Appearance• IV Major wound complication like pus
A At one point onlyB Along wound
• V Deep or severe infection with or without breakdown
Types of Surgery / class of wound
Clean Hernia repairbreast biopsy
1.5%
Clean-Contaminated
Cholecystectomy planned bowel resection
2-5%
Contaminated Non-preped bowel resection
5-30%
Dirty/infected perforation, abscess 5-30%
Risk Factors for Development of
Surgical Site Infections
Patient factor
Local factor
Microbial factor
• Older age - linear trend• Immunosuppression • Obesity • Diabetes mellitus • Chronic inflammatory process • Malnutrition • Peripheral vascular disease • Smoking• Anemia • Radiation • Steroid use
Patient factors
• Poor skin preparation • Contamination of instruments • Inadequate antibiotic prophylaxis • Prolonged procedure• Site and complexity of procedure• Local tissue necrosis • Hypoxia • Hypothermia
Local factors
•Wound Class•Prolonged hospitalization (leading to nosocomial organisms)
•Resistance
Microbial factors
Treatment
• Incisional: open surgical wound, antibiotics for cellulitis or sepsis
• Deep/Organ space: Source control, antibiotics for sepsis
Management of Incisional surgical site infection
• Removal of sutures with drainage of pus• Debridement and open wound care• delayed primary or secondary suture• 15% of postoperative wounds are treated with
antibiotics -> inappropriate -> resistance• Wound bed preparation
Wound Dehiscence and Evisceration
• Separation of abdominal wound• Protrusion of abdominal content• Mean time - 8 to 10 days• c/f– Pink serosanguinous discharge from the wound
• t/t– Reclosure of the wound
Reclosure of the wound
• Early closure in early post operative period• If evesceration – cover OT resuturing• Retention suturing is not proven advantageous• Mesh and biological implants• In a small dehiscence – secondary suturing
PREVENTION OF
SURGICAL SITE
INFECTIONS
Ignaz Semmelweis
1846Realized that
washing hand with a chlorinated lime solution decreased mortality from “puerperal fever’.
Joseph Lister
• 1883-1897• British surgeon• Used Carbolic
Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.
Guidelines for prevention of Surgical Site Infection• Information for patients and
carers• Preoperative phase• Intra operative phase• Post operative phase
Guidelines for prevention of SSI
• Explain in detail
Information for patients and carers
• Preoperative showering – none vs chlorhexidine/soap• Hair removal • Patient theatre wear• Staff theatre wear• Staff leaving the operating area• Nasal decontamination – mupirocin?• Mechanical bowel preparation• Hand jewellery, artificial nails and nail polish• Antibiotic prophylaxis
Preoperative phase
Operative Antibiotic Prophylaxis
1969
Decreases bacterial counts at surgical site
Given within 30 - 120 minutes prior to surgery - Cefazolin
MRSA - Vancomycin 1-2 hours prior to surgery
Allergic – vancomycin + clindamycin
Re-dose for longer surgery - twice the half life of drug
Single dose/ Do not continue beyond 24 hours
Do not - for clean non-prosthetic uncomplicated surgery
consider potential adverse effects
Give antibiotic treatment (in addition to prophylaxis)
Operative Antibiotic Prophylaxis
However….
• Prophylaxis not effective for– Lap cholecystectomy– Herniorraphy
• Insufficient evidence for– breast reconstruction with or without implants – abdominal hysterectomy (clean-contaminated) – uncomplicated appendicectomy in children
1
• Hand decontamination• Incise drapes• Use of sterile gowns• Gloves• Antiseptic skin preparation• Maintaining patient homeostasis – temp oxygen glucose• Diathermy• Wound irrigation and intra-cavity lavage• Antiseptic and antimicrobial agents before wound
closure• Wound dressings, Closure methods
Intra-operative phase
Guidelines for prevention of SSI
• Changing dressings• Postoperative cleansing• Use tap water for wound cleansing after
48 hours• No Topical antimicrobial agents - primary
intention• Dressings - secondary intention• Debridement• Antibiotic treatment
Postoperative phase
Guidelines for prevention of SSI
Practices to prevent SSI are therefore aimed at minimising the number of microorganisms introduced into the operative site, for example by:
• Removing microorganisms that normally colonise the skin.
• Preventing the multiplication of microorganisms.
• Enhancing the patient’s defences against infection.
• Preventing access of microorganisms into the incision postoperatively.
• Source– Schwartz’s Principles of surgery– Sabiston– Maingot’s Abdominal operations– Surgical site infection (prevention and treatment of surgical
site infection) 2008• National Collaborating Centre for Women’s and Children’s Health
– Commissioned by the National Institute for Health and Clinical Excellence
– Internet
THANK YOU