THE

PREVENTION
OF SURGICAL SITE INFECTION

HARI PARATON dr. SpOGK

KPRA-KEMENKES RI
WHO; Global Action Plan

1. Improve awareness and understanding of antimicrobial resist

ance through effective communication, education and training
2. Strengthen the knowledge and evidence base through surveillanc
e and research.
3. Reduce the incidence of infection through effective sanitati
on, hygiene and infection prevention measures.
4. Optimize the use of antimicrobial medicines in human and
animal health.
5. Develop the economic case for sustainable investment that takes
account of
the needs of all countries, and increase investment in new
medicines, diagnostic tools, vaccines and other interventions.
KOMITE PENGENDALIAN RESISTENSI ANTIMIKROBA
KEMENTRIAN KESEHATAN
 AMRIN Study, collaboration
BASE DATA KNAW and 2 hospitals. in 2000-
2005

Evaluation
Category
Sby (%) Semg (%)
NO INDICATION
FOR THERAPHY
55 - 80 20 - 53
NO INDICATION
FOR PROPHYLAXIS
13 - 55 43 - 81

Percentage of E. E. coli resistance

coli resistance to Fluroquinolon
25
25

20 20

15 MRS 15
KRS
10 10

5 5

0 0
Genta Cefotax Genta Cefotax Masuk RS Keluar RS Puskesmas

Surabaya Semarang
 kolonisasi

Antibiotika profilaksis
 DEFINISI PROFILAKSIS:
Penggunaan antibiotik sebelum, selama atau setelah
operasi, untuk pencegahan komplikasi infeksi pasca
operasi
Scottish Intercollegiate Guidelines Network 2014

Bersih
operations in which no inflammation is encountered and the respiratory,
alimentary or genitourinary tracts are not entered. There is no break in
aseptic operating theatre technique.
Bersih-kontaminasi
operations in which the respiratory, alimentary or genitourinary tracts are
entered but without significant spillage.

Scottish Intercollegiate Guidelines Network 2014

Dosis Tunggal VS Dosis Multipel

Tidak
the ada
FACT perbedaa
n
signifikan

Single-dose versus multiple-dose antibiotic prophylaxis for

the surgical treatment of closed fractures .
Slobogean.et.al. Acta Orthopaedica 2010; 81 (2): 256262
Results: A total of 540 patients were recruited; (females73.7% of total ). The performed surgical
procedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysis
showed that; ASA score > 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgical
technique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgical
prophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not
recommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were given
preoperative dose in the operating rooms. Evaluation of prescriptions for those patients showed
that; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were given
accurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for
186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions
were found to be complying with the stated criteria.
Conclusion: The
rate of wound infection was high and prophylactic
antibiotics were irrationally used. Multiple interventions are
needed to correct the situation.
 THE PROBLEM
ANTIBIOTIC
USE

Healthcare- Infection complication

blood stream /
associated AMR pneumonia / UTI / SSI
Infection 7-15 %

lebih sulit
Lebih mahal
Perlu ICU
failure morbidity and mortality
 Insidensi Infeksi Daerah Operasi (IDO)

The incidence of SSI 11.8 per 100 surgical

procedures (range 1.2 to 23.6)

ECDC. 2011
Colo-rectal 9,5
coronary artery bypass graft 3,5

caesarean section 2,9

cholecystectomy 1,4
hip prosthesis, 1.0
laminectomy 0,8
knee prosthesis 0,75
(WHO, 2011)
 WHO RESPONSIBLE ?

Pembedah
Perawat/Ners
Technical support staff,
Anesthetists
Perawatan pre-pasca
operasi
Farmasi
CSSD
Bakteri Pathogen -- IDO

Pathogen bacteria Resistance Antibiotic

E coli
Extended
Klebsiella pneumonia spectrum
Pseudomonas A Cephalosphorin
MRSA Carbapenem
Enterobactereceae Fluoroquinolone
Vancomycin
Acinetobacter
baumanii
 ANTIBIOTIK BIJAK
PRUDENT USE OF ANTIBIOTIC

3 KOMPONEN ANTIBIOTIK BIJAK

1. Penggunaan rasional
2. sesuai dengan guideline lokal
3. hindari peningkatan insidensi AMR
(Phillips, CID. 2001)

The prudent use of antimicrobials as usage of antimicrobials

which maximizes therapeutic effect and minimizes the
development of antimicrobial resistance (WHO, 2008)
SURGICAL SITE INFECTION
PREVENTION
PRE OPERATIVE
 MANDI SEBELUM OPERASI
PRE OPERATIVE BATHING
QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

Conditional Moderate
there is good clinical practice for
patients to bathe or shower prior
to surgery.
plain soap or an antimicrobial
soap
The panel decided not to
formulate a recommendation on
the use of CHG- impregnated
cloths
 DECOLONIZATION
QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
Patients undergoing cardiothoracic and Strong Moderate
orthopaedic surgery with known nasal
carriage of S. aureus should receive
perioperative intranasal applications of
mupirocin 2% ointment with or without a
combination of CHG body wash.

The panel suggests considering to treat also

patients with known nasal carriage of S. Conditional Moderate
aureus undergoing other types of surgery
with perioperative intranasal applications of
mupirocin 2% ointment with or without a
combination of CHG body wash.
 SCREENING OF ESBL COLONIZATION
AND THE IMPACT ON ANTIBIOTIC
PROPHYLAXIS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
The panel decided not to NA NA
formulate a recommendation
due to the lack of evidence.
 SAAT PEMBERIAN ANTIBIOTIK
PROFILAKSIS
QUALITY
STREN
RECOMENDATION OF
GHT
EVIDENCE
SAP should be administered prior to the Strong Low
surgical incision

The panel recommends the

administration of SAP within 120 minutes
before incision, while considering the Strong Moderate
half-life of the antibiotic
(fluroquinolone/vancomycine)

optimal timing: 30-60 minutes prior incision /cephalosporin

 MECHANICAL BOWEL
PREPARATION AND THE USE OF
ORAL ANTIBIOTICS
QUALITY
RECOMENDATION STRENGHT OF
EVIDENCE
preoperative oral antibiotics combined with Conditional Moderate
mechanical bowel preparation should be used
to reduce the risk of SSI in adult patients
undergoing elective colorectal surgery.

mechanical bowel preparation alone (without

administration of oral antibiotics) should not
be used for the purpose of reducing SSI in
adult patients undergoing elective colorectal Strong Moderate
surgery.
 CUKUR RAMBUT/BULU
HAIR REMOVAL
QUALITY
STRENG
RECOMENDATION OF
HT
EVIDENCE
patients undergoing any surgical Strong Moderate
procedure, hair should either not
be removed or,
if absolutely necessary, it should be
removed only with a clipper.
Shaving is strongly discouraged at
all times, whether preoperatively or
in the OR.
 ANTISEPSIS DAERAH OPERASI
SURGICAL SITE PREPARATION
QUALITY
STRENGH
RECOMENDATION OF
T
EVIDENCE
recommends alcohol-based Strong Low to
antiseptic solutions based on CHG moderate
for surgical site skin preparation in
patients undergoing surgical
procedures.
 CUCI TANGAN/SCRUBING
SURGICAL HAND PREPARATION
QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

surgical hand preparation should Strong Moderate

be performed by scrubbing with
either a suitable antimicrobial
soap and water or using a suitable
alcohol-based hands rub before
donning sterile gloves.
PERIOPERATIVE DISCONTINUATION
OF IMMUNOSUPPRESSIVE AGENT

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
suggests not to discontinue Conditional Very Low
immunosuppressive
medication prior to surgery
for the purpose of
preventing SSI.
 DRAPES AND GOWNS

QUALITY
STRENGH
RECOMENDATION OF
T
EVIDENCE
suggests that either sterile, disposable Conditiona moderate to
non-woven or sterile, reusable woven l very low
drapes and gowns can be used during
surgical operations for the purpose of
preventing SSI.

suggests not to use plastic

adhesive incise drapes with or without
antimicrobial properties for the purpose
of preventing SSI.
ANTIMICROBIAL-COATED SUTURES

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
CONDITIONAL MODERATE
The panel suggests the use of
triclosan-coated sutures for the
purpose of reducing the risk of
SSI, independent of the type of
surgery.
 RE-DOSING

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
Redosing intervals:

Cefazolin, every 3 or 4 hours

Clindamycin, every 4 or 6 hours
Vancomycin, no redosing or every 6
hours.
POST OPERATIVE
 PENUTUP LUKA OPERASI
ANTIMICROBIAL SKIN SEALANTS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
antimicrobial sealants Conditional Very Low
should not be used after
surgical site skin
preparation for the purpose
of reducing SSI.
 PROPHYLACTIC NEGATIVE
PRESSURE WOUND THERAPY

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

The panel suggests the use of CONDITIONAL LOW

prophylactic negative pressure
wound therapy in adult patients
on primarily closed surgical
incisions in high-risk wounds for
the purpose of the prevention of
SSI, while taking resources into
account.
 PENAMBAHAN ANTIBIOTIK
PASCA OPERASI
ANTIBIOTIC PROLONGATION

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
STRONG MODERATE
The panel recommends against
the prolongation of SAP after
completion of the operation for
the purpose of preventing SSI.
 PENUTUP LUKA
ADVANCED DRESSINGS

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE

The panel suggests not using CONDITIONAL LOW

any type of advanced dressing

over a standard dressing on
primarily closed surgical
wounds for the purpose of
preventing SSI.
ANTIMICROBIAL PROPHYLAXIS IN THE
PRESENCE OF A DRAIN AND OPTIMAL
TIMING FOR WOUND DRAIN REMOVAL

QUALITY OF
RECOMENDATION STRENGHT
EVIDENCE
preoperative antibiotic prophylaxis CONDITIONAL LOW
should not be continued in the
presence of a wound drain for the purpose
of preventing SSI.

The panel suggests removing the wound CONDITIONAL VERY LOW

drain when clinically indicated. No
evidence was found to allow making a
recommendation on the optimal timing of
wound drain removal for the purpose of
preventing SSI.
ANTIMICROBIAL STEWARDSHIP PROGRAM
JOHNS HOPKINS 2016
 TERIMA KASIH
TERIMA KASIH