SURGICAL SITE INFECTIONS

By, Dr. M Afaque Alam First year resident

Introduction
Based on NNIS system reports, SSIs are the third most frequently reported nosocomial infection, accounting for 14% to 16% of all nosocomial infections among hospitalized patients.

Consequences of surgical Site infection



Delayed healing Systemic infection & complications Increased hospital stay (7 - 14 days) Increased hospital costs (US$4,000 - $6,000) Increased use of antibiotics resistance

Psychological effects on patient/family

SSI anatomy and classification

Horan TC et al.22

Superficial Incisional SSI

Horan TC et al.22

Infection occurs  within 30 days after the operation  and infection involves only skin or subcutaneous tissue of the incision  and at least one of the following: 1. Purulent drainage, with or without laboratory confirmation, from the superficial incision. 2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. 3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by surgeon, unless incision is culture-negative. culture4. Diagnosis of superficial incisional SSI by the surgeon or attending physician.

Organ/Space SSI
Infection occurs  within 30 days after the operation if no implant is left in place  or within 1 year if implant is in place  the infection appears to be related to the operation  infection involves any part of the anatomy (e.g., organs or spaces) , other than the incision, which was opened or manipulated during an operation and at least one of the following: 1. Purulent drainage from a drain that is placed through a stab wound into the organ/space. 2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. 3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination. 4. Diagnosis of an organ/space SSI by a surgeon or attending physician.

Deep Incisional SSI

Infection occurs within 30 days after the operation if no implant is left in place within 1 year if implant is in place infection appears to be related to the operation and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following: 1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site. 2. 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 (>38C), localized pain, or tenderness, unless site is cultureculture-negative. 3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination. 4. Diagnosis of a deep incisional SSI by a surgeon or attending physician.

RISK OF SSI
Microbial contamination of the surgical site is a necessary precursor of SSI. The risk of SSI can be conceptualized according to the following relationship Dose of bacterial contamination X Virulence= Risk of surgical site infection Virulence= Resistance of the host patient


Quantitatively, it has been shown that if a surgical site is contaminatedwith >105 microorganisms per gram of tissue, the risk of SSI ismarkedly increased. Dose of contaminating microorganisms required to produce infection may be much lower when foreign material is present at the site (i.e.,102 staphylococci per gram of tissue introduced on silk sutures)

PATHOGENS ISOLATED FROM SSI

NATIONAL NOSOCOMIAL INFECTIONS SURVEILLANCE SYSTEM, 19861986-96

Percentage of Isolates 1986-1989 1990-1996 (N=16,727) (N=17,671) Staphylococcus aureus 17 20 Coagulase-negative staphylococci 12 14 Enterococcus spp. 13 12 Escherichia coli 10 08 Pseudomonas aeruginosa 08 08 Enterobacter spp. 08 07 Proteus mirabilis 04 03 Klebsiella pneumoniae 03 03 Other Streptococcus spp. 03 03 Candida albicans 02 03 Group D streptococci (non-enterococci) 02 Other gram-positive aerobes 02 Bacteroides fragilis 02
*Pathogens representing less than 2% of isolates are excluded

PATHOGENS ISOLATED FROM SUPERFICIAL SSI

J Ayub Med Coll Abbottabad 2009;21(2)

Causative Organism
E. coli Klebsiella Staph.aureus Pseudomonas Enterobacter Proteus Staph.epidermidis

No
68 23 11 05 02 02 01

%
60.7 20.5 09.8 04.0 01.7 01.7 0.9

RISK FACTORS

CDC NNIS composite Risk Index score:

One point for each of the following risk factors: Type of surgery contaminated or dirty/infected Duration of operation procedure greater than 75th percentile Underlying co-morbidities coASA score >= 3

CHARACTERISTICS THAT MAY INFLUENCE THE RISK OF SSI

Patient
        

Operation
             

Age Nutritional status Diabetes Smoking Obesity Coexistent infections at a remote body site Colonization with microorganisms Altered immune response Length of preoperative stay

Duration of surgical scrub Skin antisepsis Preoperative shaving Preoperative skin prep Duration of operation Antimicrobial prophylaxis Operating room ventilation Inadequate sterilization of instruments Foreign material in the surgical site Surgical drains Surgical technique Poor hemostasis Failure to obliterate dead space Tissue trauma

RECOMMENDATIONS

Preoperative phase
1. Screening and decolonization Patient has been screened for MRSA using local guidelines. If found positive they have been decolonized according to the recommended protocol prior to surgery. 2. Preoperative showering Patient has showered (or bathed/washed if unable to shower) preoperatively using soap. 3. Hair removal If hair removal is required, it is removed using clippers with a disposable head (not by shaving) and timed as close to the Operating procedure as possible.

Intra operative phase

1. Skin preparation Patient s skin has been prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol solution and allowed to air dry17. (If the patient has a sensitivity povidone-iodine application is used). povidone-

2. Prophylactic antibiotics Appropriate antibiotics were administered within 60 minutes prior to Incision and only repeated if there is excessive blood loss, a prolonged operation or during prosthetic surgery.

Prophylactic antibiotics
Four principles must be followed to maximize the benefits of AMP:  Use an AMP agent for all operations in which its use has been shown to reduce SSI rates based on evidence from clinical trials or for those operations in which incisional or organ/space SSI would represent a catastrophe.  Use an AMP agent that is safe, inexpensive, and bactericidal with an in vitro spectrum that covers the most probable intraoperative contaminants for the operation.  Time the infusion of the initial dose of antimicrobial agent so that a bactericidal concentration of the drug is established in serum and tissues by the time the skin is incised.  Maintain therapeutic levels of the antimicrobial agent in both serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room. Because clotted blood is present in all surgical wounds, therapeutic serum levels of AMP agents are logically important in addition to therapeutic tissue levels. FibrinFibrinenmeshed bacteria may be resistant to phagocytosis or to contact with antimicrobial agents that diffuse from the wound space.

Intra operative phase

3. Normothermia Body temperature is maintained above 36C in the peri36 perioperative period 1818-21. 4. Incise drapes If incise drapes are used they are impregnated with an antiseptic. 5. Supplemented oxygen Patients hemoglobin saturation is maintained above 95% (or as high as possible if there is underlying respiratory insufficiency) in the intra and post operative stages (recoveryroom).

Intra operative phase

6. Glucose control A glucose level of <11mmol/l has been maintained in diabetic patients This tight blood glucose control is not considered relevant in nonnon-diabetic patients.

Post operative phase

1. Surgical dressing The wound is covered with an interactive dressing at the end of surgery and while the wound is healing Interactive wound dressing is kept undisturbed for a minimum of 48 hours after Surgery unless there is leakage form the dressing and need for a change. The principles of asepsis (non touch technique) are used when the wound is being redressed. 2. Hand Hygiene Hands are decontaminated immediately before and after each episode of patient contact using the correct hand hygiene technique. (Use of the WHO 5 moments of hand hygiene or NPSA Clean your hands campaign is recommended).

Thank you!