Rizwan Shareef presentation on the topic of infection

Rizwan Shareef presentation on the topic of infection

1. Surgical Site Infection (Wound Infection) Dr Muhammad Rizwan Shareef

2. “Constant attention to a surgical wound is as much important as a major operation by a surgeon”

3. Overview Introduction Definition Incidence Risk factors Classification Scoring Clinical features Diagnosis Differential diagnosis Management

4. Introduction Surgical site infection (SSI) is the most common preventable complications after surgery. Occurs in 2-4% of all patients undergoing inpatient surgical procedures Significant cause of mortality and morbidity Leading cause of hospital readmissions

5. Incidence The global estimate of SSI have varied from 0.5% to 15% Studies from various tertiary care hospitals in Pakistan show a wide range of SSI rates , reflecting differences in hospital hygiene, surgical protocols, and antibiotic use. Estimated SSI rate in Pakistan: 6%–33% depending on: Type of surgery Hospital setting (public vs. private) Infection control practices

6. Definition: according to center for disease control and prevention (CDC) Surgical site infections (SSI) related to a surgical procedure that occurs near the surgical site within 30 days following surgery. 90 days following surgery when an implant is involved. https://www.cdc.gov/infectioncontrol/guidelines/ssi/index.html

7. CDC : specific criteria for the diagnosis of SSIs Wounds are generally categorized as follows: 1. Superficial skin and subcutaneous tissue 2. Deep fascia and muscle 3. Organ space which includes the internal organs if the operation includes that area.

8. Classification of sources of infection Endogenous: present in or on the host e.g. SSSI following contamination of the wound from a perforated appendix Exogenous : acquired from a source outside the body such as the operating theatre (inadequate air filtration, poor antisepsis) or the ward (e.g. poor hand-washing compliance). The cause of hospital acquired infection (HAI)

9. Southampton wound grading system Grade- Appearance Grade-Appearance Grade- Appearance 0 Normal healing IIc Along wound Major complications I Normal healing with mild bruising or erythema IId Around wound IV Pus Ia Mild bruising III Clear or haemoserous discharge IVa At one point only (<2cm) Ib Considerable bruising IIIa At one point only (≤2 cm) IVb Along wound (>2cm) Ic Mild erythema IIIb Along wound (>2 cm) V Deep or severe wound infection with or without tissue breakdown; haematoma requiring aspiration II Erythema plus other signs of inflammation IIIc Large volume IIa At one point IIId Prolonged (>3 days) IIb Along sutures Bailey and love short practice of surgery 27 th edition

10. Asepsis wound score Criterion Points Additional treatment Antibiotics for wound infection Drainage of pus under local anaesthesia Debridement of wound under general anaesthesia 10 5 10 Serous discharge Daily 0-5 Erythema Daily 0-5 Purulent exudate Daily 0-10 Separation of deep tissues Daily 0-10 Isolation of bacteria from wound 10 Stay as inpatient prolonged over 14 days as result of wound infection 5 Bailey and love short practice of surgery

11. From Bacteria’s point of view.. Gram-positive cocci account for half of the infections Staphylococcus aureus (most common), coagulase- negative Staphylococcus, and Enterococcus spp S. aureus infections normally occur in the nasal passages, mucous membranes, and skin of carriers. M ethicillin-resistant S. aureus [MRSA] consists of two subtypes, hospital-acquired and community-acquired MRSA. In approximately one third of SSI cases, gram-negative bacilli Escherichia coli, Pseudomonas aeruginosa, and Enterobacter spp.) are isolated. predominant bacterial species are the gram-negative bacilli at locations at which high volumes of GI operations are performed.

12. Common Bacteria causing surgical infection Streptococci Gram positive on staining Group A streptococcus, Strep. pyogenes Streptolysin , streptolinase , streptodornase Streptococcus faecalis Sensitive to penicillin, erythromycin & cephalosporins

13. Staphylococci Gram positive cocci Suppuration in wounds / implanted prostheses B-lactamase producers-resistant to penicillin Flucloxacillin , vancomycin , aminoglycosides, cephalosporins Linezolid, teicoplanin , daptomycin Staph epidermidis : vascular cannulas/ catheters

14. Clostridia Gram positive Clostridium perfringens – gas gangrene Clostridium tetani – tetanus Clostridium difficile – pseudomembranous colitis Imidazoles and Cephalosporins

15. In the National Nosocomial Infections Surveillance System, the risk of patients is stratified according to three important factors : Wound classification (contaminated or dirty); L onger duration operation, defined as duration that exceeds the 75th percentile for a given procedure; Medical characteristics of patients determined by American Society of Anesthesiology classification of III, IV, or V (presence of severe systemic disease that results in functional limitations, is life-threatening, or is expected to preclude survival from the operation) at the time of operation .

16. Risk factors for surgical site infections

17. Types of surgical procedures

18. Clinical Features Superficial incisional SSI: Pain or tenderness Localised swelling Erythema Local rise of temperature Purulent drainage

19. Clinical Features Deep incisional SSI: Fever (>38 C) Localised pain or tenderness Purulent discharge Wound dehiscence

20. Clinical Features Organ / space SSI Fever(>38 C) Hypotension Nausea, vomiting Abdominal pain or tenderness Elevated transaminases Jaundice Purulent drainage Abscess

21. Diagnosis History and examination Imaging Ultrasound CT scan with oral contrast Cultures

22. Differential Diagnosis Reactions to suture material/ dressings Subcutaneous hematoma Seroma Stitch abscess

23. Prevention of SSI: Pre operative preparation Bath/scrub Part preparation Antibiotic prophylaxis Intra operative Strict antiseptic precautions during surgery Hand hygiene Post operative care

24. Precautions- intra operative Careful handling of tissues . Meticulous dissection, hemostasis , and debridement of devitalized tissue . Compulsive control of all intraluminal contents Preservation of blood supply of the operated organs Elimination of any foreign body from the wound

25. Precautions- intra operative Maintenance of strict asepsis by the operating team (e.g., no holes in gloves; avoidance of the use of contaminated instruments; avoidance of environmental contamination, such as debris falling from overhead) Thorough drainage and irrigation with warm saline of any pockets of purulence in the wound Ensuring that the patient is kept in a euthermic state, is well monitored, and is fluid-resuscitated Expressing a decision about closing the skin or packing the wound at the end of the procedure

26. Antibiotics used in treatment and prophylaxis of surgical infection Penicillin Flucloxacillin Ampicillin, amoxicillin and co-amoxiclav Piperacillin and ticarcillin Cephalosporins Aminoglycosides Vancomycin and teicoplanin Carbapenems Metronidazole Ciprofloxacin

27. Prophylaxis To be most effective, the antibiotic is administered intravenously within 60 minutes before the incision so that therapeutic tissue levels have developed when the wound is created and exposed to bacterial contamination.

28. Type of surgery Infection rate with prophylaxis (%) Infection rate without prophylaxis (%) Clean 1-2 1-2 Clean-contaminated 3 6-9 Contaminated 6 13-20 Dirty 7 40 SSI rates relating to wound contamination with and without using antibiotic prophylaxis Bailey and love Short practices of surgery

29. Management Treatment of SSIs depends on Depth of the infection For superficial and deep SSIs skin staples are removed over the area of the infection, and a cotton-tipped applicator may be easily passed into the wound, with efflux of purulent material and pus. if the fascia has separated or purulent material appears to be coming from deep to the fascia, there is concern about dehiscence or an intra-abdominal abscess that may require drainage or possibly a reoperation. The presence of crepitus in any surgical wound or gram-positive rods (or both) suggests possibility of infection with C. perfringens Rapid and expeditious surgical débridement is indicated Most postoperative infections are treated with healing by secondary intention. Delayed primary closure may be considered after close observation of the wound for 5 days if the wound looks clean

30. Management Wound debridement D rainage Lavage: warm normal saline Chlorhexidine /hydrogen peroxide/sodium hypochlorite ??? Medications??

31. Thank you