SURGICAL SITE INFECTION

IN SURGERY
Dr. Soetomo Hospitals Experience

Paul L.Tahalele MD, PhD

Consultant of thoracic Cardiovascular Surgery
Chief of Cardiac Surgical Team
Surabaya Heart & Vascular Center
Airlangga University Medical Center Dr. Soetomo Teaching Hospital
Surabaya - Indonesia

SSI, what is the problem faced by

Indonesian Healthcare System
1.

2.

3.

Indonesia is a big country consist thousands

Islands (220 million people) has big healthcare
problem with limited heatlh care resources.
Indonesian has approximately 110 type A & B
State Hospital.
The Indonesian Healthcare system is aware of
the dangers of Healthcare Associated Infection
(HAI).
So far, there are no published data on infection
control in Indonesia (focus on SSI).
(Offra Duerink. J. of Hosp. Infection 2006 Feb; 62(2):219-29)

SSI, what is the problem faced by

Indonesian Healthcare System
Based on above, the Director of Dr. Soetomo Hospital
establish AMRIN program (Antimicrobial Resistance in
Indonesia), it is joint collaboration with Prof. Dr. Henri A.
Verbrugh, a Microbiologist from Erasmus University
Medical Center Amsterdam. The result of AMRIN study
2001:
a. The quality assessment of Ab. Usage in Department of Surgery
in Surabaya shows that there is no indication between 30-68%
and inappropriate Ab. use between 19-21%
b. Dr. Offra Duerink et al reported the result of surveillance of
health care associated infection in Indonesian Hospital (20012002), with focus on SSI: The Prevalance of SSI was 5.3% both
after clean and clean contaminated and 12% after dirty operation
(J of Hosp Infection 2006 Feb; 62(2): 219-29). This study was
performed in two Indonesian University Hospitals (Surabaya &
Semarang)

The next step: establish a program together with all

surgical staff members and commit to overcome that
problems.
In 2003:
1. After evaluation of the result of AMRIN Study
2001, we renewed & updating the antibiotic
guideline 1992 (1st Ab guideline in Dr. Soetomo
Hospital).
2. Socialization to the staff performed around 3
months
3. Training activities to the 60 residents of surgery
4. Begin action with the new antibiotic guideline at
the Depart. of Surgery Dr. Soetomo General
Hospital

SSI

or Infection in Surgery
contributed by many risk
factors

2. Risk of
infection
1.Skin
preparation
2.Operating
room
3.Operative
technique
4.Tissue
oxygenation
MW Mulholland & GM Doherty (2006).
Complications in Surgery, Lippincott Williams
& Wilkins, Philadelpia, pp 114-125

Alcohol 70%

water, Sterile ??

water, Sterile

Definition SSI:
A surgical wound infection occurs when
micro-organisms from the skin, other
parts of the body or the environment
enter the incision that the surgeon
makes through the skin
Physical symptoms: pus, inflammation,
swelling, pain and fever.
Etiology: Staphylococcus aurens is the
most common causative organism

A Major Surgical Site Infection

can be a Catastrophe
Sternotomy, unstable sternum,
mediastinitis

Potential complications of SSIs:

1. tissue destruction

2. failure of the wound to close

properly resulting in incisional and
deep hernias
3. septic thrombophlebitis
4. recurrent pain
5. disfiguring and disabling scars

And
6. SSIs prolong the length of
hospitalization

Prevention of SSI
1.
2.
3.
4.
5.
6.
7.
8.
9.

Tissue oxygenation
Bowel preparation
Treatment of remote infection
Skin preparation
Operating room environment
Operating room personnel
Antibiotic prophylaxis
Operative care
Incision care

MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins,
Philadelpia, pp 114-125

Prevention of SSI
1.Tissue oxygenation
2. Bowel preparation

3. Treatment of remote infection

MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins,
Philadelpia, pp 114-125

Prevention of SSI
4. Skin preparation
1. Preoperative Shower
2. Hair Removal
3. Operating Room Skin Preparation
MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins, Philadelpia, pp 114-125

4. Skin
preparation

Prevention of SSI
5. Operating Room Environment
1. Ventilation
2. Room Surfaces
3. Instrument Sterilization

Prevention of SSI
6. Operating room personnel
1. Surgical Scrub
2. Surgical Garb and

Gloves
3. Sterile Gloves and
Gown
Sterile??

Prevention of SSI
7. Antibiotic prophylaxis .. !
Total Number of Operation and Antibiotic use at the Department of Surgery
Dr. Soetomo Hospital
Kind of Operation

Antibiotic Use

Elective

Emergency

Non

Prophylatic

Theraupetic

TOTAL
2004

2147
(64,7%)

1172
(35,3%)

3319
(100%)

1214
(36,6%)

1736
(52,3%)

369
(11,1%)

3319
(100%)

TOTAL
2005

2302
(68%)

1088
(32%)

3390
(100%)

1299
(38%)

1469
(43%)

622
(19%)

3390
(100%)

TOTAL
2006

2441
(64,9%)

1320
(35,1%)

3761
(100%)

1281
(34,1%)

2149
(57,1%)

331
(8,8%)

3761
(100%)

TOTAL
2007

2648
(66,4%)

1341
(33,6%)

3989
(100%)

1237
(31%)

2328
(58,4%)

424
(10,6%)

3989
(100%)

TOTAL
2008

2525
(67,5%)

1214
(32,5%)

3739
(100%)

995
(26,6%)

2289
(61,2%)

455
(12,2%)

3739
(100%)

1547
(100%)

606
(28,02%)

1111
(71,36%)

436
(28%)

1547
(100%)

Year

TOTAL
2009

Since the introduction of benzylpenicillin

about 60 years ago, antimicrobial resistance
is an increasing problem with nowadays
sometimes serious consequences for the
treatment of patients with infectious disease.
Worldwide (multi) resistant bacteria like
methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci
(VRE), extended-spectrum brtalactamase
producing (ESBL) Klebsiella pneumoniae,
penicillin-resistant Streptococcus
pneumoniae, Acinetobacter baumannii
against which colistine is the only effective
treatment, and multiresistant
Mycobacterium tuberculosis, trouble
patients, doctors and policy makers.
Prof. PJ Van Den Broek, 2005

Benefits Of Antibiotic Prophylaxis

Reduces

the SSI and patient

morbidity
Reduces the duration and costs of
health care ( when the costs
associated with the management of
post operative infection are
considered, the cost effectiveness
of prophylaxis becomes evident )
Shorten hospital stay.

Prophylactic Antibiotics in
Cardiac Surgery
1.
2.
3.

First-generation cephalosporin: - cefazolin (effectiviness against

gram-positiveorganism)
Second-generation cephalosporins: - cefamandole & - cefuroxime
Vancomycin is used if thre is a severe allergy to penicillin/
cephalosporin (+) amino glycoside: untuk gram-negative
Bacteriemie suspect : Rapid screening test for S. aureus/ culture

4.

Mupirocin

emperic treatment
(Superazon/ Beta laktamase)

Therapeutic Antibiotic

Indonesia must be smarter in

handing out antibiotics
Indonesian colleagues seem not to
be aware of the hazardous
consequences of overuse and
misuse of antibiotics in their
patients.
The Jakarta Post. Monday, August 20, 2007
Prof. Henri A. Verbrugh, Jakarta
http://www.thejakartapost.com/Archives/ArchivesDet2.asp?FileID=20070820.E03 (1 van 3)24-8-2007 17:30:09

Prevention of SSI

8. Operative care:
1. Drains/ Dead Space

Management
2. Tissue Handling

Prevention of SSI
9. Incision care

Wound Care and Infectious Complications

B. Nosocomial Infections
2. Preventive measures that may reduce
the incidence of nosocomial infections
include:
a.
b.
c.

Hand washing by the health care team

Chlorhexidine gluconate 0.12% oral rince
Early removal of invasive catheters, especially
central lines, upon suspicion of infection

(Robert M Bajor. Manual of Perioperative Care in Cardiac Surgery 4ed, 2005)

Wound Care and Infectious Complications

B. Nosocomial Infections
2. Preventive measures that may reduce the
incidence of nosocomial infections include:
d. Avoidance of empiric use of broad-spectrum
antibiotics and prolonged use when no longer
necessary
e. Aggressive ventilatory weaning protocols to
reduce the duration of mechanical ventilation
and other steps to avoid ventilator-associated
pneumonia.
f. Raising the threshold for blood transfusion
(transfuse if HCT < 26%)
(Robert M Bajor. Manual of Perioperative Care in Cardiac Surgery 4ed, 2005)

Prevention of Surgical Site

Infection

Preoperative
- Risk reduction
- Infection control
- Appropriate antibiotic prophylaxis

Intraoperative
- Infection control
- Maintain normoxia (?) and normothermia
- Maintain euglycemia (cardiac)
- Re-dose antibiotic if surgery > 4 hours

Prevention of Surgical Site

Infection
Postoperative

- Infection control
- Maintain normoxia (?) and normothermia
- Maintain euglycemia
- Do not administer additional antibiotics
-

Certainly limit to no more than 24 h

Remove drains/catheters as soon as

possible

Management of Superficial
Incisional SSI
OPEN

the incision
Cultures not necessary if antibiotics not
indicated
Antibiotics not indicated if no or minimal
erythema/ no systemic toxicity
GENTLE local incision care

ALCOHOLS
Advantages
Broad spectrum
Effective against
Most gram-positive
Most gram-negative
Fungi
Viruses
Rapid acting
1.
2.

3.

Disadvantages
Short persistence
Potentially drying to skin
Potentially flammable
Spores may be resistant
Not applicable for mucosal
membranes

Larson EL. APIC guideline for handwashing and hand antisepsis in health care setting. Am J Infect control.
1995;23(4):251-266
Boyce JM. Pilted D Guideline for hand hygiene in healthcare settings. Recommendations of the healthcare
Infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force,
MMWR Recomm Rep. 2002 Oct 25;SI (RR-16):1-45
Crosby CT Mares AK. Skin antisepsis : past, present and future. JVAD. 2001: 1-6.

CHLORHEXIDINE
Advantages
Broad spectrum
Effective against
Most gram-positive
Most gram-negative
Fungi
Viruses
Yeast
Highly persistent
Effective in the presence of organic
material (e.g.blood)
Minimally absorbed

1.
2.
3.
4.

Larson EL. Am J Infect Control. 1995:23(4):251-269

Hidalgo E. Domiguez C. Toxicol In Vitro. 2001;15(45):271-276
Mald DG. et al Lancet. 1991:338:339-343
Larson E, Bobo L, J Emerg Med 1992;10(1):7-11

Disadvantages
Direct instilation can damage ears
or eyes
Direct contact with nerve tissue can
be damaging
Minimal activity against spores

5.
6.
7.

Boyce JM, et al. MMWR Recomm Rep. 2002 Oct

25: 51(RR-16):1-4
Anders N. Wollensak J. J Cataract Refract Surg.
1997;23(6):959-960
Perez R, et al Laryngoscope. 2000; 110(9); 15221527

Organisms Cultured from SSIs

CHX-Alcohol

Povidone-Iodine

Staph aureus

8 (7/0/1)

24 (12/2/2)

Staph epidermidis

5 (4/1/0)

7 (4/2/1)

Enterococci

6 (3/2/1)

6 (2/2/2)

Streptococci

1 (0/0/1)

10 (5/3/2)

E.Coli

3 (1/1/1)

1 (1/0/0)

Klebsiella

2 (1/0/1)

2 (1/0/1)

Bacteroides

7 (3/2/2)

5 (1/2/2)

Recommend to: DarouicheRO, Wall MJ Jr. Itani KMF, et al N Engl J Med 2010;362:18-26

Recommended Antibiotic
Prophylaxis
Surgical Service

Routine Antibiotic

Allergy

Burns

Cefazolin

Clindamycin

Cardiac

Cefazolin plus
Vancomycin

Vancomycin

Thoracic

Cefazolin or
Cefuroxime

Vancomycin OR
Clindamycin

Colorectal

Cefazolin plus
Metronidazole

Gentamicin plus
Clindamycin

General Surgery

Cefazolin

Clindamycin

Hepatobiliary
(complicated)

Ampicillin/Subbactam

Gentamicin plus
Vancomycin

Plastic,Reconstructive &
Hand Surgery

Cefazolin

Clindamycin or
Vancomycin

Vascular

Cefazolin (add
Vancomycin if graft)

Vancomycin

Healthcare Associated Infection

(HCAIs) and resistant organisms

Urinary

catheters

ESBLsNDMs

Respiratory

HAP VAP and ITU

GRE

Vascular catheters and prosthetics

MRCNS

Bacteraemias SSIs and cSSTIs

MRSA

Clostridium difficile

(CDI)

Antibiotic overuse

ASEPSIS
Additional treatment
Serous discharge
Erythema
Purulent exudate
Separation of deep tissues
Isolation of bacteria
Stay in hospital 14 days

Interval data

Definition of surgical site infection

Accurate audit
Surveillance MUST go to 30 days+
Unbiased blinded trained observer
Scoring systems
-if we are to have mandatory reporting who will
undertake it and who will pay?

MRSA screening
MRSA serious risk to
surgical patients screen
all elective patients?
Reduce bacterial load
(including MSSA?)
approoriate local
antimicrobial use

Report of Surgical Site Infection (SSI) Period 2005-2009

Depart. of Surgery Dr. Soetomo Hospital Surabaya

Classification of
Operative Wound

% SSI (+)
2005

% SSI (+)
2006

% SSI (+)
2007

% SSI (+)
2008

% SSI (+)
2009

TOTAL
2005-2009
(5 Years)

Clean
(Lit. IR: 1-5 %)

1.72%
(19/1101)

1.47%
(24/1637)

1.44%
(19/1328)

1.76%
(17/967)

1.59%
(17/1063)

1.57%
(96/6091)

Clean Contaminated
(Lit. IR: 8-11 %)

2.10%
(9/428)

2.74%
(97/1386)

2.29%
(24/1048)

2.23%
(86/673)

1.94%
(9/463)

2.37%
(95/3998)

Contaminated
(Lit. IR: 15-20 %)

2.22%
(1/45)

5.56%
(2/36)

7.50%
(3/40)

6.25%
(2/32)

4.88%
(4/82)

5.11%
(12/235)

Dirty & Infected

(Lit. IR: 27-40 %)

7.69%
(3/39)

9.75%
(4/41)

12.50%
(4/32)

8.33%
(3/36)

5.19%
(4/77)

8.00%
(18/225)

1.97%
(32/1623)

2.19%
(68/3100)

2.04%
(50/2443)

2.17%
(37/1708)

2.02%
(34/1685)

2.09%
(221/10559)

Total

* Data up-date Nov. 2010

* Surabaya, before 2003: ILO (SSI) 5.3%.

Atlanta, USA: 1.5%

Report of SSI: 2005-2009

Division of Thoracic & Cardiovascular Surgery
Dr. Soetomo Hospital Surabaya - Indonesia
Case/Year

2005

2006

2007

2008

2009

TOTAL

SSI

Classification of Elective Operation

Clean

4/350

7/466

6/571

9/575

5/534

2496

31

1.24%

Clean Contaminated

1/31

0/32

0/3

1/28

0/8

102

1.96%

Contaminated

0/6

0/1

0/2

0/0

0/12

21

0%

Dirty

1/4

1/12

0/4

0/3

0/1

24

8.33%

Total

6/391

8/511

6/580

10/606

5/555

2643

35

1.32%

* Data up-date Nov. 2010

Conclusion 1

* To improve the use of antibiotics a major

change in behavior of prescribers of antibiotics
is needed.

* Results of SSI in physical symptoms as

the body tries to fight the infection. There
may be pus, inflammation, swelling, pain
and fever.
* Four classification of operation:
1. clean operation
2. clean contaminated,
3. contaminated and 4. dirty.

Conclusion 2

* The patient should be assessed for factors

that can be corrected in the pre-op. period:
1. Shower with an antibacterial soap the
night before the operation.
2. Must not be shaved the night before, as
the risk as SSI is clearly increased by
bacteria.
* Management of operating room,
preparation of the skin, management of the
incision including tissue handling, drain
and wound treatment are important to
patients.

CONCLUSIONS 3

SSI : Balance?
Patient factor

OR environment

Operation
- shaving

- skin preparation
- surgical technique
- hypothermia
- foreign body
-

prophylactic antibiotics

The key to success is collaboration & efficiency.

(John Hopkins Manual of Cardiac Surgical Care, 1997)
2008 SSI symposium, Hong Kong

Thank
you