SSI

Dr Bidur Marasini InternDepartment of General Surgery

Defination
SSIs: the most common nosocomial,infections in surgical patients and account for 38% of all such infections. (by Centers for Disease Control and Prevention ) 2/3 superficial or deep incisional tissues

1/3 involve organs or spaces entered during an operation

Types of SSI and classification

The CDC National Nosocomial Infection Surveillance System has developed a standardized set of criteria that includes clinical and laboratory findings for defining SSIs

A B C
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A :SUPERFICIAL INCISIONAL SSI

Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision, WITH 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 4. Diagnosis of the superficial incisional SSI by the surgeon or attending physician BACK

 Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and infection involves deep soft tissues, With at least 1 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 culture 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

B: DEEP INCISIONAL SSI

4. Diagnosis of a deep incisional SSI by a surgeon or attending physician BACK

C: 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 and the infection appears to be related to the operation and infection involves any part of the anatomy, other than the incision, which was opened or manipulated during an operation, WITH 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 BACK

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

OPERATION Duration of surgical scrub Skin antisepsis Preoperative shaving Preoperative skin preparation Duration of operation Antimicrobial prophylaxis

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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

4 most common Pathogens

Staphylococcus aureus: S. aureus is the most common organism recovered from SSIs, and is present in the nares of nearly 30% of healthy adults. Coagulase-negative staphylococci Enterococcus species Escherichia coli

Presentation and Management

incisional site infection:classic symptoms of redness,local heat ,swelling and pain. Mostly in 5th or 6th postoperative day but may be apparent as early as the 3rd day (usually as redness and swelling). Low-grade pyrexia (102F) may be present, and the cellulitic changes progress steadily if the wound is not opened:opened, a culture/sensitivity If frankly purulent fluid is present, the cellulitic portion of the wound is opened widely to adequately assess the depth of infection.

 A gauze dressing is placed ,fluid to evacuate helps to prevent premature apposition of the skin edges. With frequent dressing ,wound is carefully inspected to assess whether further exploration or opening of the wound is necessary. If frankly necrotic tissue is observed, the wound is opened completely down to the fascia, and evidence of fasciitis is sought. A cloudy gray fluid with frank necrosis of the fascia suggests the presence of necrotizing fasciitis..

 Usually gram-positive cocci or gram-negative rods is presented , gram-positive rods suggests the presence of Clostridium perfringens Then fascia should then be debrided in the operating room at once to eradicate the infected tissue. Crepitus in the tissue may be a sign of clostridial myonecrosis. Gram stain and culture of suspicious incisional infection are therefore mandatory

Prevention
Surgical antibiotic prophylaxis refers to a short course of systemic antibiotics, beginning immediately before the start of an operation and continuing for only one or two doses postoperatively. Intraoperative prophylactic antibiotics are administered every 3 to 4 hours, or more frequently if blood loss and replacement exceed 2 units.

 The goal of antibiotic prophylaxis is to maintain the operative levels of antibiotics during operative exposure of the tissue and for a short period thereafter. The indication for antibiotic prophylaxis is based on the surgeon's preoperative prediction of how the wound will be classified at the end of the operation.

 Antibiotics are administered when systemic signs of infection are present or when cellulitis is present beyond the edges of the wound. Initial antibiotic therapy should include broad coverage for gram-positive and aerobic gramnegative organisms but should be broadened if signs of infection do not remit within 48 hours or culture results dictate a change in therapy.

 Clean wound are not normally taken as an indication for antibiotic prophylaxis unless a prosthetic material / device is inserted /unless an SSI would have devastating effects . Breast surgery, massive obesity, diabetes are sometimes also considered indications for antibiotic prophylaxis. Wounds that are classified as dirty-infected are left open for a therapeutic course of antibiotics rather than for antibiotic prophylaxis. Only wounds that are classified as clean-contaminated are an indication for antibiotic prophylaxis.

 Cephalosporins are the most frequently used antibiotics for prophylaxis. In the presence of allergy to cephalosporins or penicillin, vancomycin or clindamycin is administered. Cefazolin (Kefzol) has sufficient gram-positive and gramnegative coverage to be useful or most clean-contaminated procedures. For intestinal tract procedures, 2nd gen cephalosporin such as cefoxitin, or metronidazole is usually administered to provide broader coverage against colonic flora. Patients who appear septic before emergency surgery are usually treated with "triple" antibiotic coverage, including gentamicin, clindamycin, and ampicillin (or vancomycin).

 For elective operations on the colon or rectum, antibiotic prophylaxis is usually supplemented with a formal "bowel prep" in which the lower bowel is mechanically cleansed by oral nonabsorbable fluid (e.g., GoLYTELY), cathartics, or antibiotic-containing irrigation together with the administration of nonabsorbable oral antibiotics in divided doses beginning the day before surgery.

 Preoperatively, patient-related factors like that can be altered should be addressed. Diabetes should be under tight control; smoking should be eliminated, if possible, for 2 to 4 weeks before surgery; and indolent distant site infections (e.g., dental infections) should be treated. A preoperative shower with germicidal soap may also be recommended.

 TPN a means of reducing the risk of an SSI is controversial. Although malnutrition is associated with a higher risk of SSIs, the role of total parenteral nutrition (TPN) to reduce this risk is uncertain.

 Operative techniques that can reduce the risk of SSIs include proper skin preparation, careful placement of drapes, and protection of the wound edges from contaminated fluids and viscera. Rigorous attention to the principles of asepsis, by anesthesiologists and nurses as well as the surgeon, is also important. The most important operative factor is the adherence to careful surgical technique.

 The maintenance of effective homeostasis, prevention of hypothermia, gentle handling of tissues, removal of all devitalized tissue, avoidance of inadvertent enterotomies, obliteration of dead-space regions in the wound, use of monofilament suture, and use of closed-suction drains that exit body cavities through separate stab wounds are all important principles of expert surgical technique.

 In wounds classified as contaminated or dirty, the use of delayed primary closure, or allowing the wound to heal per primum, will also reduce the rate of incisional SSIs. In delayed primary closure, the skin is left open and covered with a sterile dressing. The dressing is left undisturbed for 4 to 5 days, at which time it is removed using aseptic technique. If healthy granulation tissue visualized, the skin edges are then approximated , and an additional dressing is applied for 24 to 48 hours.

 In wounds left to heal by Primary intention, sterile dressings are changed daily or more frequently beginning on the first postoperative day. Topical reduction of microorganisms may be effected by the use of mild bactericidal dressing solutions such as 0.25% acetic acid, Dakin solution, or Silvadene ointment. Mild-to-moderate contamination is also reduced by frequent changes of saline-dampened finemesh gauze

TAKE HOME MESSAGE

Strict Aseptic Precaution Gentle tissue handling Appropriate use of antibiotics for prevention of SSI

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