Wound Infection

Surgical site infections (SSI)

Definitions of SSI

Superficial incisional SSI: Infection involves only skin and subcutaneous tissue of incision. Deep incisional SSI: Infection involves deep tissues, such as fascial and muscle layers also superficial and deep incision sites and organ/space SSI draining through incision. Organ/space SSI: Infection involves any part of the anatomy in organs and spaces other than the incision, which was opened or manipulated during operation.

Types of SSI

Superficial incisional SSI

  

Occurs within 30 days after the operation Involves only the skin or subcutaneous tissue At least 1 of the following:
Purulent drainage is present. Organisms are isolated from fluid/tissue of the superficial incision. At least 1 sign of inflammation (eg, pain or tenderness, induration, erythema, local warmth of the wound) is present. The wound is deliberately opened by the surgeon. The surgeon or attending physician declares the wound infected

Deep incisional SSI

  

Occurs within 30 days of the operation or within 1 year if an implant is present Involves deep soft tissues of the incision At least 1 of the following:
Purulent drainage is present from the deep incision but without organ/space involvement. Fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation. A deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination. The surgeon or attending physician declares that a deep incisional infection is present

Organ/space SSI

Organ/space SSI  Occurs within 30 days of the operation or within 1 year if an implant is present  Involves anatomical structures not opened or manipulated during the operation  At least 1 of the following:
Purulent drainage is present from a drain placed by a stab wound into the organ/space. Organisms are isolated from the organ/space by aseptic culturing technique. An abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination. A diagnosis of organ/space SSI is made by the surgeon or attending physician

Causes Microbiology

Most SSIs are contaminated by the patient's own endogenous flora The usual pathogens on skin and mucosal surfaces are gram-positive cocci gastrointestinal surgery intrinsic bowel flora, gram-negative bacilli, and gram-positive microbes, including enterococci and anaerobic organisms Gram-positive organisms, particularly staphylococci and streptococci, account for most exogenous flora involved in SSIs

Pathogens causing Wound Infections

Pathogen Staphylococcus aureus Coagulase-negative staphylococci Enterococci Escherichia coli Pseudomonas aeruginosa Enterobacter species Proteus mirabilis Klebsiella pneumoniae Other streptococci Candida albicans Group D streptococci Other gram-positive aerobes 7 Bacteroides fragilis Frequency (%) 20 14 12 8 8 7 3 3 3 3 2 2 2

Host factors

Systemic factors: age, malnutrition, hypovolemia, poor tissue perfusion, obesity, diabetes, steroids, and other immunosuppressants. Wound characteristics: nonviable tissue in wound; hematoma; foreign material, including drains and sutures; dead space; poor skin preparation, including shaving; and preexistent sepsis (local or distant). Operative characteristics: poor surgical technique; lengthy operation (>2 h); intraoperative contamination, including infected theater staff and instruments and inadequate theater ventilation; prolonged preoperative stay in the hospital; and hypothermia

Risk Factors for Development of Surgical Site Infections

Patient factors Older age Immunosuppression Obesity Diabetes mellitus Chronic inflammatory process Malnutrition, Anemia Peripheral vascular disease Radiation Carrier state (e.g., chronic Staphylococcus carriage) Local factors Poor skin preparation Contamination of instruments Inadequate antibiotic prophylaxis Prolonged procedure Local tissue necrosis Hypoxia, hypothermia Microbial factors Prolonged hospitalization (leading to nosocomial organisms)

9Toxin secretion
Resistance to clearance (e.g., capsule formation)

Wound Contamination
Classification Description
Uninfected operative wound No acute inflammation Closed primarily Respiratory, gastrointestinal, biliary, and urinary tracts not entered No break in aseptic technique Closed drainage used if necessary Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage No evidence of infection or major break in aseptic technique Example: appendectomy Nonpurulent inflammation present Gross spillage from gastrointestinal tract Penetrating traumatic wounds <4 hours Major break in aseptic technique Purulent inflammation present Preoperative perforation of viscera Penetrating traumatic wounds >4 hours

Risk (%)

Clean (Class I)

<2

Clean-contaminated (Class II)

<10

Contaminated (Class III)

20

Dirty-infected (Class IV) 10

40

The National Nosocomial Infection Surveillance (NNIS) risk index

risk index (1) American Society of Anesthesiologists (ASA) Physical Status score >2 (2) class III/IV wound (3) duration of operation greater than the 75th percentile for that particular procedure

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American Society of Anesthesiologists (ASA) Classification of Physical Status

ASA Score 1 2 3 4 5
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Characteristics Normal healthy patient Patient with mild systemic disease Patient with a severe systemic disease that limits activity but is not incapacitating Patient with an incapacitating systemic disease that is a constant threat to life Moribund patient not expected to survive 24 hours with or without operation

Predictive Percentage of SSI Occurrence by Risk Index

At Risk Index Predictive Percentage of SSI

1.5

2.9

6.8

13.0

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Time Relations
Early (24-48h); streptococci and clostridia, Immunosuppression Usual; (5-10d); others Delayed (2-4w); infection of hematoma or seroma

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Lab

Staining methods: Gram stain simple, quick. Culture techniques: both aerobic and anaerobic. Fungal cultures. Then sensitivity testing Newer techniques  Tests for antigens from the organism through enzymelinked immunoassay (ELISA) or radioimmunoassay  Detection of antibody response in the host sera  Detection of RNA or DNA sequences or protein from the infective organism  Polymerase chain reaction (PCR) to detect small amounts of microbe DNA.

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RECOMMENDATIONS FROM THE HOSPITAL INFECTION CONTROL PRACTICES ADVISORY COMMITTEE FOR THE PREVENTION OF SURGICAL SITE INFECTIONS

Do not operate on patients with active infections Do not shave patient in advance Control glucose in diabetic patients Stop tobacco use in patient Have patient shower with antiseptic soap Prepare skin with appropriate agent Surgeon's nails should be short Surgeons scrub hands Exclude infected surgeons Give prophylactic antibiotics when indicated Maintain prophylactic antibiotic levels during operation Keep O.R. doors closed

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RECOMMENDATIONS FROM THE HOSPITAL INFECTION CONTROL PRACTICES ADVISORY COMMITTEE FOR THE PREVENTION OF SURGICAL SITE INFECTIONS

Use sterile instruments Avoid flash sterilization Wear a mask Cover all hair Wear sterile gloves Use gowns and drapes that resist fluid penetration Gentle tissue handling Closed suction drains (when used) Delayed primary closure for heavily contaminated wounds Sterile dressing for 24- 48 hr SSI surveillance with feedback to surgeons

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Recommendations for Prophylactic Antibiotics

antibiotics had to be in the circulatory system at a high enough dose at the time of incision to be effective clean-contaminated and contaminated wounds clean procedures in which prosthetic devices is implanted

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Recommendations for Prophylactic Antibiotics

The antibiotic should be administered preoperatively as close to the time of the incision as is practical before induction of anesthesia in most situations. The antibiotic should have activity against the pathogens likely to be encountered. Postoperative administration of preventive systemic antibiotics beyond 24 hours has not been demonstrated to reduce the risk of SSIs.

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Recommendations for Prophylactic Antibiotics

good tissue penetration to reach wound involved. cost effectiveness. minimal disturbance to intrinsic body flora

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Antibiotics as Indicated by Probable Infective Microorganism

Operation Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic procedures Appendectomy, biliary procedures Colorectal surgery Gastroduodenal surgery Expected Pathogens Recommended Antibiotic

S aureus, coagulase-negative staphylococci

Cefazolin 1-2 g

Gram-negative bacilli and anaerobes Gram-negative bacilli and anaerobes Gram-negative bacilli and streptococci S aureus, Staphylococcus epidermidis, gram-negative bacilli S aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approach Gram-negative bacilli, enterococci, anaerobes, group B streptococci Gram-negative bacilli

Cefazolin 1-2 g Cefoxitin 1-2 g Cefazolin 1-2 g

Vascular surgery

Cefazolin 1-2 g

Head and neck surgery

Cefazolin 1-2 g

Obstetric and gynecological procedures 21 Urology procedures

Cefazolin 1-2 g

Cefazolin 1-2 g

Special situations
 

Elective colon surgery: Mechanical cleansing and antibiotics Dietary restrictions. Whole gut lavage ; 10% mannitol solution, Fleet's phosphosoda, or polyethylene glycol, usually is performed on the day of surgical intervention. Enteral antibiotic regimes with oral neomycin and erythromycin being the most popular combination, metronidazole and tetracycline. Catheter- related infections: Morbidity and mortality (up to 20% in patients with catheter-related bloodstream infections).

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Newer concepts in the prevention of SSIs

 

close regulation of blood sugar in patients with diabetes,. body temperature; failure to maintain intraoperative core body temperature within 11.5C of normal increases the SSI rate by a factor of 2. oxygenation. Maintaining or increasing oxygen delivery to the wound by increasing the inspired oxygen concentration administered to the patient perioperatively has also been shown to reduce the incidence of SSIs.

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Treatment
incision and drainage without the addition of antibiotics. Antibiotic therapy is reserved for patients in whom evidence of severe cellulitis is present, or who manifest concurrent sepsis syndrome. The open wound often is allowed to heal by secondary intention

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Further Care
Inpatient Care:

increased hospital stay due to SSI 7-10 days increasing costs by 20% Occasionally, wound debridement and subsequent packing and frequent dressing is necessary to allow healing by secondary intention.

Outpatient Care: Most patients with wound infections are managed in the community. Management usually takes the form of dressing changes, which usually is by secondary intention.

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