M E C O E L W

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SURGICAL SITE WOUND INFECTIONS

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BY: Rtr. DR. MAHAR NAVEED SARWAR FCPS-II TRAINEE,WARD # 26,JPMC

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IMPORTANT TERMS:
Normal flora Various bacteria and fungi that are the permanent residents of the certain body parts without causing harm Colonization Presence and multiplication of a new organism that is not the part of normal flora Infection Invasion of normally sterile host tissue by a virulent microorganism OR Its invasion of organism into the body, following a breach in the local or systemic host defense leading to Systemic and local signs of inflammation 5/7/12

NORMAL FLORA OF THE GI TRACT

Lactobacil li Streptococci Lactobacilli Enterobacteriac eae Aerobic + Anaerobic Microbial Populations

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Bacterimia: Invasion of blood by viable bacteria without causing any systemic upset Systemic inflammatory response

IMPORTANT TERMS:

syndrome SIRS:

It is bodys inflammatory response to both

infective and non-infective cause i.e. pancreatitis,trauma,vasculitis Defined by presence of any TWO of the following:
Temperature >38.0C or<36.0C Heart rate > 90/m R/R > 20/min WBC >12000 or <4000

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SURGICAL SITE INFECTIONS (SSIs)

3rd most common nosocomial infection (after

PNEUMONIA & UTI)

Most common nosocomial infection among

surgery patients

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Criteria for defining SSIs

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 Superficial surgical site infection (SSSI):

Occurs within 30 days after operation Involves only skin and subcutaneous tissue

CRITERIA FOR DEFINING SSI

with any of the following

purulent discharge with or without laboratory confirmation; bacteria isolated from culture of wound; clinical signs (any one or more of following)
pain/tenderness localized swelling Redness heat

diagnosis of superficial SSI by attending surgeon.

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 Deep surgical site infections (DSSI)

Occurs within 30 days after operation if no implant is

placed or within 1 year if implant is placed Involves deep soft tissue e.g.: fascia and muscles with any of the following

Purulent discharge from deep incision but not from organ/space component of the surgical site Deep incision dehisces spontaneously or deliberately opened by surgeon to evacuate pus Clinical signs (one or more of following)
fever > 38 C localized pain tenderness

Abscess/other evidence of deep infection Diagnosis by attending surgeon

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 Organ/ Space infection:

Occurs within 30 days after operation if no implant is placed or

within 1 year if implant is placed Involves the body cavities and its organs e.g.. abdominal abscess after anastomotic leak And any of the following

purulent discharge from the organ or a drain in space; organisms isolated from an aseptically obtained culture of fluid or tissues in organ/space; abscess or other evidence of infection involving organ/space found on :

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direct examination during reoperation or by histopathological or radiological examination

FURTHER CLASSIFICATION
SOURCE OF INFECTION

a) Primary /endogenous: acquired from community or endogenous source such as following a perforated peptic ulcer) b)Secondary / exogenous(HAI): Infection arises following a complication that is not directly related to wound i.e. acquired from theater, ward

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CONTNUED;
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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CONTNUED;
SEVERITY

a) Minor
when there is discharge without Cellulitis or

deep tissue destruction With nil to mild systemic response

b) Major
When there is spontaneous discharge of

significant amount of pus or Partial or total dehiscence of the deep fascial layers of wound or if systemic illness is present.
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WOUND ASSESMENT
For surgical wound assessment several

scoring systems are employed especially ASEPSIS scoring Southampton wound assessment scale
These enable surgical wound healing to be graded

according to specific criteria, thus providing more objective assessment of wound.

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CLASSIFICATION OF SURGICAL WOUND

Class I wound (clean)

Class I wounds are the simple

surgeries without violation of the hollow visceral structures in a non inflamed, atraumatic wound. e.g. inguinal hernia repair. No entry into GI, GU, Biliary, or respiratory tract These wounds rarely become infected Average infection rates are 1.5%
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Class II Wound (Clean-Contaminated)

Class II wounds involve

controlled entry into a hollow visceral structure. e.g.cholecystectomy and elective colon resections Respiratory, GI, GU, or Biliary tract entered under controlled conditions Average infection rates expected are 7.5%
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Class III Wounds (Contaminated)

Traumatic wounds Breaks in sterile

technique Gross spillage from GI tract Acute, nonpurulent inflammation Average anticipated infection rates are 15%

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Class IV Wounds (Dirty)

Old traumatic wounds Devitalized tissue Clinical infection

present at the time of operation Perforated hollow viscus Average expected infection rates are 35%

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Microbiology

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NATURAL DEFENSE MECHANISMS OF HUMAN BODY Mechanical barriers:

Intact epithelial surfaces

Chemical barriers: Low gastric PH Humoral barriers: Antibodies Compliment system Opsonins Cellular barriers: Phagocytic activity by cells like macrophages,neutrophils,NK cells
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During surgery or trauma all of these mechanisms may be compromised ..!!!!!????

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PATHOGENESIS FOR INFECTION

Bacterial dose Virulence

Impaired host resistance

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RISK FACTORS FOR SSIs

Metabolic (Diabetes and Uremia) Malnutrition (Obesity and starvation ) Nicotine use Steroid use Radiotherapy Chemotherapy Disseminated cancers and AIDS Poor perfusion (shock and ischemia) Foreign body material Poor surgical technique(increased dead tissue and haematoma formation) Hospital stay
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Nicotine use

Delays primary wound healing Increase the risk of SSI

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PREVENTION OF SSIs
PROPHYLAXIS PREOPERATIVE CARE AND PREPARATION POSTOPERATIVE PRECAUTIONS

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PROPHYLAXIS
I/V administration of ABx within 30 minutes of induction Single dose of prophylactic ABx is equivalent to

therapeutic ABx Repeat ABx 8 hourly and 16 hourly if

Surgery is prolonged (> 3 hours) Excessive blood loss in operative field(1500ml) Prosthesis placement Its empirical cover against the expected pathogen Cost Local hospital policies (that are based on local trends of resistance)

Choice of ABx depends

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

AB X

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TIMINGS OF PROPHYLACTIC ANTIBIOTIC ADMINSTRATION AND SUBSEQUENT RATES OF SSIs

TIME OF ADMINSTRATIION Early (2-24 hours before

incision)

PERCENT SSIs 3.8% 0.6% 1.4% 3.3%

Preoperative (0-2 hours before

incision)

Perioperative (3 hours after

surgery)

Postoperative (more than 3

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SUGGESTED PROPHYLACTIC REGIMENS FOR THE OPERATIONS AT RISK TYPE OF SURGERY Vascular ORGANISM ENCOUNTERD SUGGESTED PROPHYLACTIC REGIMEN Staph epidermidis Staph aureus Aerobes gram ve bacilli Staph.A Staph.E Enterobacteriaceae Enterococci 3 doses of flucloxacin, Vancomycin or rifampcin if MRCNS/MRSA 1-3 doses of broad spectrum cephalosporin 1-3 doses of 2nd generation cephalosporin + metronidazole

Orthopaedic Oesophago-gastric

Biliary

Enterobacteriaceae mainly 1 dose of 2nd generation Ecolab cephalosporin Enterococci Enterobacteriaceae Anaerobes (bacteroides) 1-3 doses of 2nd generation cephalosporin with or without metronidazole 1-3 doses of 2nd generation cephalosporin with metronidazole

Small bowel

Appendix/colorectal

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Enterobacteriaceae Anaerobes (bacteroides)

PRE-OPERATIVE PREPARATION
Short hospital stay

Medical staff should always wash their hands in between

Lowers the risk of MRSA/MRCNS and others HAIs

patients Strict aseptic care of intravenous lines; Isolation of infected cases. Preoperative shaving should be avoided, if necessary it should be undertaken just before the surgery

Because minor skin injuries promote bacterial colonization and double the risk of SSIs) Hair clipping is best with lowest infection rates

Attention to the theater technique & discipline

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Number of staff and their movement in & out of theater should be kept to minimum Proper ventilation of theater Proper instruments sterilization

CONTINUED
Proper Scrubbing & skin preparation

Thorough scrubbing including nails should be done before first case in the morning Subsequent cases merely involve washing up to elbow (as repeated scrubbing releases more organisms) Application of antiseptic over incision site decreases skin microbial colony counts

Avoidance of preoperative hypothermia and

supplementation of O2 in recovery room have proved to reduce the risk of SSIs

of silk as a suture for skin closure

Drains: increase incisional SSI risk. Increase in the incidence of SSIs is also noted with the use
If there is silk in the tissue the minimum number of organism needed to start an infection is reduced logarthimatically (bailey & love 25th edition vol:I,page #35)

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NAME

commonly used antiseptic solutions

PRESENTATION USES COMMENTS Skin preparation Effective against Skin prep:, surgical scrub gram+ve in dilute sol: in open wound Skin preparation Safe ,fast acting, broad Skin prep:, surgical scrub spectrum with some sporicidal activity in dilute sol: in open wound Hand washing Instrument and surface cleaning Skin preparation Pseudomonas may grow in stored contaminated solutions should be reserved for the use as disinfectant

Chlorhexidine (hibiscrub) Alcoholic 0.5% Aqueous 4%

Povione-iodine (betadine)

Alcoholic 10% Aqueous 7.5%

Citrimide (savlon)

aqueous

Alcohols

70% ethyl, isopropyl

hypochlorites

Aqueous Instrument and surface Toxic to tissue preparations(eusol,milto cleaning n,chloramine T) (debriding agent in open wound) Aqueous bisphenol Skin prep: hand washing Act against gram -ve

Hexachlorophane

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POSTOPERATIVE PRECAUTIONS
Patients with established MRSA infections

should be
Nursed in a separate room require specialist bacteriological advice about the antibiotic treatment needed. All attending staff (medical and nursing) should wear protective clothing (plastic apron and gloves) that is discarded in a designated container immediately the patient is seen. This is followed by thorough disinfection of the hands.

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TREATMENT OF SSIs
Antibiotics are rarely used as the sole agents

to eradicate surgical infections; usually they constitute adjuvant treatment to surgery, e.g.
excision of the infecting focus, drainage of abscesses, debridement, lavage of infected serous cavities.

For established infections, the culture and

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sensitivity of the organisms to antibiotics is performed

CONTINUED..
Efflux of purulent material and pus removal of sutures and clips if suppuration is evident Fascia is intact:

debridement Irrigated with N/S and packed to its base with saline-moistened gauze

Fascia separated:
drainage

or reoperation healing by secondary intention

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Discharge planning
The intent of discharge planning: maintain integrity of the healing incision, educate the patient about the signs and symptoms of infection, advise the patient about whom to contact to report any problems.

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