Surgical site infection revised

Something new to undergraduate

1. Surgical site infection Presented by DR.MD AB QUIYUM PHASE A,HEPATOBILIARY SURGERY

2. History Egyptian…………………….putrefaction Greek and Assyrian…..prophylaxis Hippocrates……………...wine and vinegar Romans……………………..drain of pus Koch’s postulate……….organism concept /germ theory Semmelluiz ………………..hand washing Magic Bullet……………. sulphonamide Allexander ……………..penicillin…….antiseptic surgery….aseptic surgery

3. DEFINATION Bacterial contamination of wound during or after surgery usually 30 days and one year for prosthetic surgery .

4. Terminology 1 . Contamination 2 Colonization 3. Infection

5. TYPE The Centers for Disease Control and Prevention (CDC) classifications of SSI as follows: 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; this also includes infection involving both 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

6. Other Classification ETIOLOGY…… A. Primary the wound is primary site of infection B. secondery Following a complication that is not directly related to wound. Severity….. A. minor B. major

7. Cont.. Time… A. Early Infection present within 30 days of procedure B. Intermediate Occurs between one and three month C. Late Present more than three months after surgery

8. COMMON ORGANISM

9. Factor affecting SSI A. Patient factor B. Pre operative factor C. Operative characters D. post operative factors

10. Factors that determine whether a wound will become infected Host response Virulence and inoculum of infective agent Vascularity and health of tissue being invaded (including local ischaemia as well as systemic shock) Presence of dead or foreign tissue Presence of antibiotics during the ‘decisive period’

11. Causes of reduced host resistance to infection Metabolic: malnutrition (including obesity), diabetes, uraemia , jaundice Disseminated disease: cancer and acquired immunodeficiency syndrome (AIDS) Iatrogenic: radiotherapy, chemotherapy, steroids Risk factors for increased risk of wound infection Malnutrition (obesity, weight loss) Metabolic disease (diabetes, uraemia, jaundice) Immunosuppression (cancer, AIDS, steroids, chemotherapy and radiotherapy) Colonisation and translocation in the gastrointestinal tract Poor perfusion (systemic shock or local ischaemia ) Foreign body material Poor surgical technique (dead space, haematoma )

12. PATHOGENESIS

13. Clinical feature: A superficial incisional SSI may produce pus from the wound site. Samples of the pus may be grown in a culture to find out the types of germs that are causing the infection. A deep incisional SSI may also produce pus. The wound site may reopen on its own, or a surgeon may reopen the wound and find pus inside the wound. An organ or space SSI may show a discharge of pus coming from a drain placed through the skin into a body space or organ. A collection of pus, called an abscess, is an enclosed area of pus and disintegrating tissue surrounded by inflammation. An abscess may be seen when the surgeon reopens the wound or by special X-ray studies.

14. Superficial incisional SSI characterized by the following: Occurs within 30 days after the operation Involves only the skin or subcutaneous tissue Includes at least one of the following: (a) purulent drainage is present (culture documentation not required); (b) organisms are isolated from fluid/tissue of the superficial incision; (c) at least one sign of inflammation ( eg , pain or tenderness, induration, erythema, local warmth of the wound) is present; (d) the wound is deliberately opened by the surgeon; (e) the surgeon or clinician declares the wound infected Note: A wound is not considered a superficial incisional SSI if a stitch abscess is present; if the infection is at an episiotomy, a circumcision site, or a burn wound; or if the SSI extends into fascia or muscle

15. Deep incisional SSI characterized by the following: Occurs within 30 days of the operation or within 1 year if an implant is present Involves deep soft tissues ( eg , fascia and/or muscle) of the incision Includes at least one of the following: (a) purulent drainage is present from the deep incision but without organ/space involvement; (b) fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation; (c) a deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination; (d) the surgeon or clinician declares that a deep incisional infection is present

16. Organ or space SSI is characterized by the following: Occurs within 30 days of the operation or within 1 year if an implant is present Involves anatomic structures not opened or manipulated during the operation Includes at least one of the following: (a) purulent drainage is present from a drain placed by a stab wound into the organ/space; (b) organisms are isolated from the organ/space by aseptic culturing technique; (c) an abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination; (d) a diagnosis of organ/space SSI is made by the surgeon or clinician

17. SCORING SYSTEM ( for wound assessment) A. ASEPSIS scoring B. SOUTHAMPTON wound assessment scale.

18. SIGN OF NECROTIZING INFECTION 1.Odema beyond area of erythema 2.crepitus 3.skin blistering 4.fever (often absent) 5.Greyish discharge 6.focal skin gangrene 7.shock ,coagulopathy , multi organ failure

19. TREATMENT 1.Proper antibiotic according to culture sensitivity. 2.Efflux of purulent material and pus If facia is intact ……Debridement irrigation with N/S packed to its base with saline moistened gauze If fascia separated drainage or reoperation

20. PREVENTION A.Pre operative b. OT discipline C.During operation D.Post operative

21. Prophylactic antibiotics should be initiated within one hour before surgical incision, or within two hours if the patient is receiving vancomycin or fluoroquinolones . Patients should receive prophylactic antibiotics appropriate for their specific procedure. Prophylactic antibiotics should be discontinued within 24 hours of surgery completion (within 48 hours for cardiothoracic surgery). Postoperative 6 a.m. blood glucose levels should be controlled (200 mg per dL [11.10 mmol per L] or less) in patients undergoing cardiac surgery. Surgical site hair removal should be appropriate for the location and procedure (e.g., clippers, depilation, no hair removal). Patients undergoing colorectal surgery should be normothermic (96.8°F [36°C] or greater) within the first 15 minutes after leaving the operating room. ( the core infection prevention measures )

22. Avoiding surgical site infections Staff should always wash their hands between patients Length of patient stay should be kept to a minimum Preoperative shaving should be done immediately before surgery Antiseptic skin preparation should be standardised Attention to theatre technique and discipline Avoid hypothermia perioperatively and ensure supplemental oxygenation in recovery

23. Preoperative care: prophylactic antibiotic : consider side effect and possible side effect ,timing

24. The 7 S Bundle was created by Maureen Spencer, RN, M.Ed , Infection Preventionist Consultant. 1.safe or practice 2.screen 3. Shower 4.Skin preparation 5.solution 6.suture 7.skin incision preparation

25. Conclusion In spite of the use of prophylactic antibiotics, SSIs are still a real risk of surgery and represent a substantial burden of disease for both patients and healthcare services in terms of morbidity, mortality and economic cost.

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