SURGICAL SITE INFECTIONS

PREVENTION AND CARE

Dr.T.V.Rao MD

Dr.T.V.Rao MD

Surgical Site Infection

CDC defines
A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.
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Definition of CDC
Wound infection is most commonly characterized by the classic signs of redness (rubor), pain (dolor), swelling (tumor), elevated incisional tissue temperature (calor) and systemic fever. Ultimately, the wound is filled with necrotic tissue, neutrophils, bacteria and Proteinaceous fluid that together constitute pus.
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Surgical site infections

Surgical site infections have been shown to compose up to 20% of all of healthcareassociated infections. At least 5% of patients undergoing a surgical procedure develop a surgical site infection
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When the Infection occurs

Surgical site infection may range from a spontaneously limited wound discharge within 710 days of an operation to a lifethreatening postoperative complication, such as a sternal infection after open heart surgery
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How Surgical Infections caused

Most surgical site infections are caused by contamination of an incision with microorganisms from the patient's own body during surgery. Infection caused by microorganisms from an outside source following surgery is less

common.

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surgical site infections

3rd most common nosocomial infection 14-16% Most common nosocomial infection among surgery patients 38% 2/3 incisional 1/3 organ
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Epidemiology: SSI data 2006-2011

Surgical site infections: are the third most prevalent HCAI in hospital inpatients are present in 1% of hospital inpatients surveyed (2011) account for 1.4% of overall HCAI incidence in England developed in 10% of large bowel operation cases* are largely preventable
*this figure applies to procedures tracked under the national SSI surveillance programme
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Information on this slide updated June 2012

Risk Factors for SSI: The Patient

Age Nutritional status

Diabetes
Nicotine use Obesity Coexistent infection Colonization Altered immune response Long preoperative stay
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Risk Factors for SSI: Pre- and Intraoperative

Inappropriate use of antimicrobial prophylaxis Infection at remote site not treated prior to surgery Shaving the site vs. clipping Long duration of surgery Improper surgical team hand antisepsis Environment of the room (ventilation, sterilization) Surgical attire and drapes Asepsis Surgical technique: hemostasis, sterile field
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Improper skin preparation

Pathogenesis

Bacterial dose

Virulence

Impaired host resistance

Surgical Infection Prevention Project

Started in August 2002, by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) Based on 2 findings:

Estimates indicate that 40-60% of all SSIs are preventable

Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25-50% of operations

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Selected Surgical Procedures Increases the Risk

Cardiac Coronary Artery Bypass Graft (CABG) Colon

Hip & Knee Arthroplasty

Abdominal & Vaginal Hysterectomy Vascular Surgery: Aneurysm repair Thromboendarterectomy Vein Bypass
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Important Definitions
Colonization
Bacteria present in a wound with no signs or symptoms of systemic inflammation Usually less than 105 cfu/mL

Contamination
Transient exposure of a wound to bacteria Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy
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 Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day. Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation.
Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.

CDC on Skin Preparation

Use Appropriate Antiseptic

Use an appropriate antiseptic agent for skin preparation. Apply preoperative antiseptic skin preparation in concentric circles moving toward the periphery. The prepared area must be large enough to extend the incision or create new incisions or drain sites, if necessary.
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Antiseptic skin preparation in concentric circles moving toward the periphery

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 The surgical site and surrounding areas should be clean. The skin around the surgical site should be free of soil and debris. Removal of superficial soil, debris, and transient microbes before applying antiseptic agent(s) reduces the risk of wound contamination by decreasing the organic debris on the skin.
Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.

On Skin Preparation Many present with open wonds

Cleaning Carries Greater Importance

Cleansing should be accomplished by any of the following methods before surgical skin preparation:

Patient showering and/or shampooing before arrival in the practice setting

Washing the surgical site before arrival in the practice setting, or Washing the surgical site immediately before applying the antiseptic agent in the practice setting
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Instruction on Skin Preparation (contd)

When indicated, the surgical site and surrounding area should be prepared with an antiseptic agent
Antiseptic agents should be.used in accordance with the manufacturers written instructions. Antiseptic agent(s) should have a broad range of germicidal action.

Many Disinfectants

Variance in protocols and practice

Contd;
Infection
Systemic and local signs of inflammation Bacterial counts 105 cfu/mL Purulent versus nonpurulent

Surgical wound infection is SSI

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Preoperative phase (hair removal)

Do not routinely use hair removal Do not use razors for hair removal, as they increase 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
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Criteria for defining SSIs

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Classification of surgical site infections

Superficial incisional infection: this is defined as a surgical site infection that occurs within 30 days of surgery and involves only the skin or subcutaneous tissue of the incision, and meets at least one of the following criteria
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Nurses must have minimal Knowledge on Superficial Infection

Criterion 1: Purulent drainage from the superficial incision Criterion 2: The superficial incision yields organisms from the culture of aseptically aspirated fluid or tissue, or from a swab and pus cells are present b. the clinician diagnoses a superficial incisional infection
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What is Stich Infection

Stitch abscesses are defined as minimal inflammation and discharge confined to the points of suture penetration, and localised infection around a stab wound. They are not classified as surgical site infections
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Supporting Evidence
Criterion 3: At least two of the following symptoms and signs: - pain or tenderness - localised swelling - redness - heat and a. the superficial incision is deliberately opened by a surgeon to manage the infection, unless the incision is culture-negative
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Symptoms include:
Redness and pain

around the area where you had surgery Drainage of cloudy fluid from your surgical wound Fever
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Further Classification
Etiology
a) Primary The wound is the primary site of infection

b)Secondary
Infection arises following a complication that is not directly related to wound
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Who are at Risk

In general the risk of SSI increased in the older age group (65 years) except in cardiac, bile duct/liver/pancreatic, cholecystectomy, gastric, limb amputation and vascular surgery where the reverse was observed with the risk being higher in younger patients (<65 years). The risk of SSI increased among patients who were overweight or obese (BMI 25 kg/m2) in CABG, cardiac non-CABG, breast and knee surgery.
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Contd;
Time
a Early Infection presents within 30 days of procedure b Intermediate Occurs between one and three months c) Late Presents more than three months after surgery
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Contd; Severity
a Minor Wound infection is described as minor when there is discharge without cellulitis or deep tissue destruction b 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.
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Microbiology Nature of the Isolates A major study

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Preoperative factors influences Preoperative antiseptic showering Preoperative hair removal Patient skin preparation in the operating room Preoperative hand/forearm antisepsis
Antimicrobial prophylaxis
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How to Prepare the Patients

Preoperative

antiseptic showering

Decreases skin microbial colony counts No evidence of benefit to reduce SSI rates
Preoperative

hair removal

Shaving: @ immediately before the operation: SSI rates 3.1% @ shaving within 24 hours preoperatively: 7.1% @ having performed >24 hours: SSI rate > 20%. Depilatories: @ lower SSI risk than shaving or clipping @ hypersensitivity reactions
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Preoperative phase (hair removal)

Do not routinely use hair removal Do not use razors for hair removal, as they increase 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

Preoperative phase (antibiotic prophylaxis)

Give antibiotic prophylaxis before: - clean surgery for the placement of a prosthesis or implant - clean-contaminated surgery - contaminated surgery Do not routinely use for clean non-prosthetic uncomplicated surgery Use local antibiotic formulary and consider adverse effects Consider prophylaxis on starting anaesthesia, or earlier for operations using a tourniquet

Intraoperative phase
Prepare the skin immediately before incision using an (aqueous or alcoholbased) antiseptic preparation povidone-iodine or chlorhexidine are most suitable Cover surgical incisions with an appropriate interactive dressing at the end of the operation

Changing a dressing
Before you start, make sure you have gauze pads, a box of medical gloves, surgical tape, a plastic bag, and scissors. Then:
Prepare supplies by opening the gauze packages and cutting new tape strips. Put on medical gloves. Loosen the tape around the old dressing.
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How to Deal with Problem

Inspect the incision for signs of infection. Hold a clean, sterile gauze pad by the corner and place over the incision. Tape all four sides of the gauze pad. Put all trash, including gloves, in a plastic bag. Seal plastic bag and throw it away.

Wash your hands.

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How to Deal with Problem

Remove the old dressing. Remove the gloves. At this point, clean the incision if your doctor told you to do so. (See instructions below.) Wash your hands, and put on another pair of medical gloves
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Cleaning an incision
To clean the incision:
Gently wash it with soap and water to remove the crust. Do not scrub or soak the wound.

Do not use rubbing alcohol, hydrogen peroxide, or iodine, which can harm the tissue and slow wound healing.
Air-dry the incision or pat it dry with a clean, fresh towel before reapplying the dressing.
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Do not
Don't expose your incision to direct sun for 3 to 9 months after surgery. As an incision heals, the new skin that is formed over the cut is very sensitive to sunlight and will burn more easily than normal skin. Bad scarring could occur if you get sunburn on this new skin.
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Have a policy on Sending the Specimens for Culturing

Develop clear guidance for staff on when a wound swab should be taken: there should be some signs of infection, e.g. discharging pus, redness, swelling, heat, pain.

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Preparing to Collecting the Swabs from Wounds

The person collecting specimens should decontaminate hands to reduce the risk of transfer of transient organisms on the healthcare workers hands to the patient. Apply gloves (remove dressing as appropriate) to protect the health care workers hands.
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Ideal way to Collect the Wound Swabs

The wound should be cleansed with sterile saline to irrigate any purulent debris (Stotts 2007) to achieve a clean culture site and to avoid obtaining a culture from the pus on the surface of the wound. Moisten the swab with sterile saline before taking sample. In dry wounds a moistened swab will attach bacteria more effectively.
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Collecting a SWABS for Bacterial Culturing

Always take a swab from a newly cleaned wound.

Cleanse with normal saline or sterile water

Take a swab by moving in a Z pattern over the wound and turning the swab at the same time Punch biopsy (Physician only) Do Not swab necrotic or slough tissue
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Collecting the Swab

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Collecting the Specimen

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A case of Sternal Infection

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*When to order the Culturing wounds

*Culture

swab of a wound should only be taken if clinical infection is suspected. Or else the results are misleading
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Interpretation of Microbiology Results

Microbiology results should be interpreted in conjunction with clinical information. Advice from a Medical Microbiologist should be sought if there is doubt about the interpretation of a result. A positive

microbiology report is not a clear indication of infection. The result must

also indicate the presence of pus cells or there should be other clinical signs of an infection
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Details of the Wound and Antibiotic Therapy should be included in the Requests to Laboratory

The details regarding the wound should be recorded on the request formDocument condition of wound and evidence of infection including clinical symptoms any antibiotic treatment the patient on must be recorded, Clinical details will assist the microbiologist in making an accurate diagnosis.
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Request for Improvement of Requests

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Collect the Specimens with Optimal care and Scientific Spirit

Properly collected specimens will give optimal benefit in proper identification of the causative organisms and appropriated Antibiotic suggestions.
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Wound Cleansing
- Normal

Saline or Sterile Water

Irrigate with 2030 ml syringe Use 18 angiocath 4-6 inches above the wound
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Prophylactic antibiotics
Class 1 = Clean Prophylactic Class 2 = Clean contaminated antibiotics indicated Class 3 = Contaminated Class 4 = Dirty infected Therapeutic antibiotics

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Do Remember
Once the incision is made, antibiotic delivery to the wound is impaired. Must give before incision!

ABX

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Use/Choice of Antibiotics
Use only when indicated Start with broad spectrum antibiotics designed to cover likely pathogens Take cultures when possible Deescalate spectrum once pathogen is know Have a plan for duration
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Preoperative phase (antibiotic prophylaxis)

Give antibiotic prophylaxis before: - clean surgery for the placement of a prosthesis or implant - clean-contaminated surgery - contaminated surgery Do not routinely use for clean non-prosthetic uncomplicated surgery Use local antibiotic formulary and consider adverse effects Consider prophylaxis on starting anaesthesia, or earlier for operations using a tourniquet
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Standardized infection ratio

The standardized infection ratio (SIR) is a summary measure used to track HAIs at a national, state, or facility level over time. The SIR adjusts for the fact that each healthcare facility treats different types of patients. For example, the experience with HAIs at a hospital with a large burn unit cannot be directly compared to a facility without a burn unit.
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Learn to Calculate the Infection Rates at you Hospitals

The SIR compares the actual number of HAIs in a facility or state with the baseline U.S. experience (i.e., standard population), adjusting for several risk factors that have been found to be most associated with differences in infection rates.
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Surgeons should be Role Models Never forget to wear the Mask

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 Infection is every bodys concern, it is not just Nursing staff, but Doctors have a great Role. Infections can make or break the future of Hospitals including the career of the Surgeons I wish every body is partner in Prevention of Hospital acquired infections.

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Say Good Bye to Infections Just Wash your Hands

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