SURGICAL SITE INFECTION PRESENTATION.pptx

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1. SURGICAL SITE INFECTION PRESENTER: DR KALUMA SUPERVISOR: DR NGALULA RESEARCH TEAM: SURGERY DEP TEAM DATE: 20/03/24

2. LAYOUT Introduction Statistics Classifications Risk factors Guidelines on SSI Prevention Local study

3. INTRODUCTION Surgical site infection refers to an infection that occurs after surgery in the part of the body where the surgery took place. (CDC, ) European Centre for Disease Prevention and Control, 2016, adds that t he infection occurs within 30 days of the operation. It leads to; Increased morbidity Increased mortality Increased duration of hospital stay Increased cost

4. CLASSIFICATION OF SSI According to depth of involvement Superficial incisional SSI Deep incisional SSI Organ/Space incisional SSI

5. SUPERFICIAL INCISIONAL SSI Occurs < 30 days Affects skin and sub-cut tissue Has atleast 1 of the following: Purulent discharge Organism isolated culture sample. Incision with localized sites of inflammation. Diagnosis by physician/surgeon

6. DEEP INCISIONAL SSI Occurs < 30 days involves deep tissues i.e. fascial and muscles Has atleast 1 of the following: Purulent discharge from deep tissue. Spontaneous dehisces or opened & culture + or not cultured with fever >38 C and signs of inflammation. Abscess or evidence of infection on direct exam, invasive procedure, imaging or histo -path Diagnosis by physician/surgeon

7. ORGAN/ SPACE INCISIONAL SSI Occurs < 30 days or within 1 year if implant related. Involves structures deeper beyond muscle and fascia. Has atleast 1 of the following: Purulent discharge from drain Organism isolated culture sample. Abscess or evidence of infection on direct exam, invasive procedure, imaging or histopath Diagnosis by physician/surgeon

8. OTHER CLASSIFICATIONS Timing of Infection Early Infection presents within 30 days of procedure b) Intermediate Occurs between 1 and 3 months c) Late Presents more than 3 months after surgery

9. Severity Minor Discharge without cellulitis or tissue destruction b) Major Pus discharge with tissue breakdown Partial or total dehiscence of the deep fascial layers of wound Presence of systemic illness

10. RISK FACTORS Patient factor Local Factor Microbial Factor

11. Patient Factor Old age Immunosuppression Malnutrition Anemia Diabetes mellitus Chronic inflammatory process Peripheral vascular disease Steroid use

12. Local Factors Poor skin preparation Local tissue necrosis Hypoxia Hypothermia Contamination of instruments Prolonged procedure Site and complexity of procedure

13. Microbial factor Wound Class Prolonged hospitalization (nosocomial microbes) Resistance

14. GUIDELINES ON SSI PREVENTION Pre-op Intra-op Post-op

15. Pre-op measures RECOMMENDATIONS STRENGTH Encourage Pre-op showering day of surgery or day before surgery using plain soap or antimicrobial. Conditional recommendation, moderate quality of evidence Discourage routine shaving, if necessary use electric clippers. Conditional recommendation, moderate quality of evidence Theatre wear for patient should be appropriate for OT and procedure. Operating team should remove hand jewellery, artificial nails and nail polish before OT.

16. Pre-op measures cont.. Antimicrobial prophylaxis within 120 min before incision (clean, clean-contaminated and contaminated surgery) taking into account the timing and pharmacokinetics. Strong recommendation, moderate quality of evidence Enhanced nutrition support. Conditional recommendation, very low quality of evidence Perioperative discontinuation of immunosuppressants. (Conditional recommendation, very low quality of evidence

17. Intra operative measures RECOMMENDATION STRENGTH Laminar flow of air in operating room environment from clean to less clean areas. Conditional recommendation, low quality of evidence Pre- op handwashing asepsis Strong recommendation, moderate quality of evidence Surgical attire (sterile gowns and gloves) and drapes. Conditional recommendation, moderate to very low quality of evidence Antiseptic skin preparation- Alcohol based solution of chlorhexidine or povidone-iodine. Strong recommendation, low to moderate quality of evidence Maintain normal body homeostasis -body temperature, glucose, circulation volume and oxygenation. Conditional recommendation, moderate quality of evidence

18. Post operative measures Incision Care- use an aseptic non-touch technique changing dressings The type of postoperative incision care a) Closed primarily: incision is usually covered with a sterile dressing for 24 to 48hrs b) Left open to be closed later: packed with sterile dressing c) Left open to heal by 2 nd intention: packed with sterile dressing

19. Changing dressings - use an aseptic non-touch technique for changing or removing surgical wound dressings. Postoperative cleansing -use sterile saline for wound cleansing up to 48hrs post surgery - Advise patients to shower safely 48hrs post surgery -use tap water for wound cleansing after 48hrs if the surgical wound has separated or been opened to drain pus.

20. MMH MINI STUDY IN MARCH 2024

21. With reference to the increase in the number of SSI in post op patients in the month of February. A mini-study was taken to ascertain the cause of the increased SSIs in post op patients.

22. Surgical Site Infections ( statistics from 2023 provincial report ) Descriptive analysis of SSI for level 2 and 3 hospitals in SP. Despite data quality issues, SSI rate is high

23. Surgical Site Infections High SSI rate in Level 1 hospitals. Most level 1 hospital refer their cases.

24. Surgical Site Infections comparison (Level 2 &3) Need to design Specific IPC interventions according to specialty

25. Surgical Site Infections comparison (Level 2 &3) Bukhsh, Ayman & Azhar, Nedaa & Bazaid, Albaraa & Khafaji, Rami & Alqahtani, Shaima & AlQahtani, Habnan & Alrasheedi, Naif & Almarzouq, Adeeb & Alsaggaf, Rayan & Alshehri, Waad & Alhazimi, Mohammad. (2022). Types, Causes and Complication Rates of Surgical Site Infection Post Maxillofacial Surgery. JOURNAL OF HEALTHCARE SCIENCES. 02. 154-158. 10.52533/JOHS.2022.2803. High risk of infection from Maxillofacial surgery due to organisms in oral mucosa

26. MMH January- February 2024 SSI Statistics for department of surgery Month Total Surgeries Total SSIs diagnosed Prevalence January 118 3 2.5% February 75 8 10.6%

27. Total of 11 patients where analyzed who had SSI from January to February 2024 department of surgery

28. SWAB RESULTS AT MMH DONE ON 04/03/24 Swabbed surface report Report obtained Organism/s Sensitivity tests Theatre 1 walls No growth after 24hrs incubation N/A N/A Theatre 2 walls No growth after 24hrs incubation N/A N/A Theatre 3 walls No growth after 24hrs incubation N/A N/A Theatre 1 hand washing room Heavy growth of gray large ,raised, greenish colonies seen. Psuedomonus auroginosa SENSITIVE: Cotrimoxazole, Norfloxacin, Chloramphenical , Ciprofloxacillin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime Theatre 2 hand washing room Heavy growth of gray large ,raised, greenish colonies seen. Proteus valgaris SENSITIVE: Gentamycin, Norfloxacin, Chloramphenical , Ciprofloxacillin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime

29. Autoclave No growth seen after 24 hrs of incubation. N/A N/A Theatre 1 bed No growth seen after 24 hrs of incubation. N/A N/A Theatre 2 bed Medium growth of raised white colonies seen Staphylococcus aureus spp. SENSITIVE: Gentamycin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime Norfloxacin, Chloramphenical , Ciprofloxacillin Theatre 3 bed No growth seen after 24 hrs of incubation. N/A N/A Chito forceps No growth seen after 24 hrs of incubation. N/A N/A

30. MSW Linen acute bed No growth seen after 24 hrs of incubation N/A N/A MSW Linen No growth seen after 24 hrs of incubation N/A N/A CSW linen Acute bed No growth seen after 24 hrs of incubation N/A N/A CSW linen No growth seen after 24 hrs of incubation N/A N/A FSW Linen Acute bed No growth seen after 24 hrs of incubation N/A N/A FSW linen No growth seen after 24 hrs of incubation N/A N/A

31. SWAB RESULTS FOR SURGICAL IN-PATIENTS WITH SSIs DONE ON 01/03/24 Patient/Ward Report obtained Organism/s Sensitivity tests Patient 1 (MSW) Small raised grey colonies seen Proteus Mirabilis SENSITIVE: Gentamycin, Norfloxacin, Chloramphenical , Ciprofloxacillin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime Patient 2 (MSW) White big raised colonies seen SENSITIVE: Gentamycin, Chloramphenical RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime, , Norfloxacin, Ciprofloxacillin Patient 3 (MSW) Grey large raised colonies Pseudomonas auroginosa SENSITIVE: cotrimoxazole, Norfloxacin, Chloramphenical , Ciprofloxacillin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime Patient 4 (FSW) Grey large raised colonies Pseudomonas auroginosa SENSITIVE: cotrimoxazole, Norfloxacin, Chloramphenical , Ciprofloxacillin RESISTANT: Ampicillin, Ceftriaxone, Cefotaxime

32. ROOT-CAUSE ANALYSIS USING THE FISHBORNE METHOD Increased rate of SSI OT Environment Aseptic measures Pre-operative patient care Intra-operative patient care Post-operative patient care OT Instrument Sterilization Erratic administration of Pre-op Antibiotics due to Drs orders not being specific Pre-op antibiotics to incision time prolonged Use of substandard linen for patients going to theatre due to lack of theatre gowns No laminar flow of air from clean to less clean areas Lack of separate theatres for different cases due to defective anesthetic machines Poor scrubbing techniques Water supply not sterile Fumigation/ mass scrubbing schedules not always adhered Substandard wound care- (lack of mackintosh)

33. RECOMMENDATIONS To be based on gaps from analysis

34. References Surgical site infections: prevention and treatment. NICE guidelines 2020 Global guidelines for the prevention of surgical site infection, second edition. Geneva: World Health Organization; 2018: CC BY-NC-SA 3.0 IGO. United States Centers for Disease Control and Prevention. https://www.cdc.gov/HAI/ssi/ssi.html, accessed 11 July 2016. European Centre for Disease Prevention and Control. http://ecdc.europa.eu/en/publications/Publications/ 120215_TED_SSI_protocol.pdf, accessed 16 August 2016). Dr amit poudel : Surgical site infections presentation; SlideShare, 2016. Dr Clive Banda: Descriptive Analysis of Surgical Site Infections and Neonatal Sepsis for 2023. Southern Province, Zambia.