Surgical Site Infection- SSI by Okoye

Surgical Site Infection- SSI by Okoye- Take note of the peculiarities

Surgical Site Infection- SSI by Okoye- Take note of the peculiarities

1. SURGICAL SITE INFECTION (SSI) OKOYE. C

2. Outline Introduction Definition Statement of surgical importance Historical background Epidemiology Classification Aetiology / Risk factors Pathophysiology Clinical features Investigations Treatment Complications Prevention Follow up Conclusion

3. Introduction Surgical site infection (SSI) is an problem of significance in surgical patients. With documentations to this effect dating back 4000 -5000 years.

4. Introduction Definition SSI is Infection present in any location along the surgical tract after a surgical procedure within 30 days of procedure or up to 1yr after, if an implant was used

5. Statement of Surgical importance SSI is an important cause of morbidity and mortality, affectin g wound healing, length of hospital stay with economic consequences; hence prevention and effective management is key to a better wound outcome.

6. Historical background Cornelius celcius a Roman physician described the four cardinal signs of inflammation in 14-37AD Robert Koch (1879) Developed postulates to identify the association between organisms with specific diseases.

7. Historical background Ancient Egyptian papyrus (1600BC) – provided detailed information of disease including wound management with the application of various portions and grease to assist healing . Hippocrates ( 460 – 377BC)-vinegar era Gallen (Roman gladiatorial surgeon, 130 – 200AD)-pus leading us astray

8. Historical background Ignaz Semmelweis ( 1818 – 1865): demonstrated 5 fold reduction in puerperal sepsis by handwashing Joseph Lister (1867) – aseptic surgery, carbolic acid Louis Pasteur ( 1827 – 1912) – Germ theory Alexander Fleming ( 1881 – 1955) – discovery of Penicillin 1880 -Sterilization of instruments Halsted ( 1852 – 1922)- rubber gloves 1940- Antibiotic era

9. Epidemiology Seventy seven percent (77%)of the deaths of surgical patients are related to surgical wound infection(Magram,1999 ) Kirkland et al (1999) calculated a relative risk of death of 2.2 attributable to SSIs, compared to matched surgical patients without infection. It significantly increases cost of medical care for surgical patient ( -Resultant increased hospital stay due to SSI has been estimated at 7-10 days, increasing hospitalization costs by 20% (Haley, 1981).

10. Epidemiology Collated data on the incidence of wound infections probably underestimate true incidence. Most wound infections occur when the patient is discharged, and these infections may be treated in the community without hospital notification. 75% of patients with SSI present after discharge from hospital

11. Aetiology Microbes Bacteria Aerobic Anaerobic Fungi Viruses

12. Aetiology Sources of wound infection • Primary (Endogenous): Derived from the host • Secondary (Exogenous): Acquired from a source outside the body

13. Risk Factors Patient Factors Local factors Microbial Surgical factors

14. Risk Factors Patient Factors Immunosuppression Malnutrition Obesity Smoking Chronic skin disease Peripheral vascular disease Radiation Anaemia Older age

15. Risk Factors Local Factors Poor skin preparation, Surgical technique Contaminated instruments Local tissue necrosis, FB Prolonged procedures Inadequate antibiotics prophylaxis H3-Hypoxia Hypothermia Hematoma

16. Risk Factors Microbial factors Virulence of Microorganism Prolonged hospitalization –HAI Resistance to clearance ( e.g capsule formation) Toxin secretion

17. Risk Factors Surgical factors The type of procedure is a risk factor. Certain procedures are associated with a higher risk of wound contamination than others.

18. Classification I’ll discuss the classifications relevant to SSI Surgical wounds have been classified as clean, clean-contaminated, contaminated, and dirty-infected (NRC)

19. Classification Description Infective Risk (%) Clean (Class I) Uninfected operative wound No acute inflammation Closed primarily Respiratory, gastrointestinal, biliary , and urinary tracts not entered No break in aseptic technique Closed drainage used if necessary <2 Clean-contaminated (Class II) Elective entry into respiratory, biliary , gastrointestinal, urinary tracts and with minimal spillage No evidence of infection or major break in aseptic technique Example: appendectomy <10 Contaminated (Class III) Nonpurulent inflammation present Gross spillage from gastrointestinal tract Penetrating traumatic wounds <4 hours Major break in aseptic technique 15-20 Dirty-infected (Class IV) Purulent inflammation present Preoperative perforation of viscera Penetrating traumatic wounds >4 hours About 40

20. Classification Incisional surgical site infection Superficial Deep Organ/ Spaces surgical site infection

21. Classification Superficial incisional SSI (w criteria) Occurs within 30 days after the operation Involves only the skin or subcutaneous tissue At least 1 of the following: Purulent discharge from surgical site. Organisms are isolated from fluid/tissue of the superficial incision. At least 1 sign of inflammation ( eg , pain or tenderness, induration , erythema , local warmth of the wound) is present. The wound is deliberately opened by the surgeon. The surgeon or clinician declares the wound infected.

22. Classification Deep incisional SSI (w criteria) 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 At least 1 of the following: Purulent drainage is present from the deep incision but without organ/space involvement. Fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation. A deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination. The surgeon or clinician declares that a deep incisional infection is present.

23. Classification Organ/space SSI (w criteria) Occurs within 30 days of the operation or within 1 year if an implant is present Involves anatomical structures opened or manipulated during the operation At least 1 of the following: Purulent discharge is present from a drain placed by a stab wound into the organ/space. Organisms are isolated from the organ/space by aseptic culturing technique. An abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination. A diagnosis of organ/space SSI is made by the surgeon or clinician.

24. Exclusion criteria Stitch abscess (minimal inflammation/discharge confined to the points of suture penetration) Episiotomy infections or newborn circumcision scars Infected burn wound

25. Classification Major and Minor SSI Major surgical site infection :-A wound that either discharges significant quantity of pus or requires a secondary procedure to drain it. -patient may have systemic signs. Minor surgical site infection -A wound that may discharge pus or infected serous fluid but which should not be associated with excessive discomfort, systemic signs or delay in return home Advantage of this classification is to assist in audit and trials of antibiotic prophylaxis

26. P athophysiolo gy Host defences Local defences Epithelial barrier Tissue macrophages Lactoferrin , transferin Systemic defences Acquired immunity Complement system activation

27. P athophysiology Virulence of organism Adverse effect on wound through: Persistent inflammatory response - Free radical environment, secrete toxins and protease that act to degrade growth factors prevent orderly arrangement of matrix protein

28. CLINICAL FEATURES Local Pain, Discharge, tenderness Swelling Differential warmth Erythema Systemic SIRS Sepsis Severe sepsis Septic Shock

29. Investigations Confirm diagnosis Wound swab microscopy, culture and sensitivity Wound biopsy microscopy, culture and sensitivity Imaging – USS, Xray Extent of disease Full blood count + blood film Serum total protein and albumin Urea, Electrolyte and Creatinine

30. Treatment Emergency (Septic Shock, Anaemia ) Resuscitation Intravenous fluid Blood transfusion Antibiotics Nutritional support Source control (Debridement) Tetanus prophylaxis

31. Treatment Non Operative and Operative Local wound care Loose stitches Incision and drainage Debridement Wound dressing

32. Treatment Surgery Wound closure (Delayed primary closure, secondary closure)

33. Complications Early Wound dehiscence Sepsis Multiple organ dysfunction/ failure Late Impaired wound healing Osteomyelitis Incisional hernia Malignant transformation

34. Prevention Pre-op Microbial Shorten pre-op stay Antiseptic shower Maybe shaving Avoid or treat local site infection Antimicrobial prophylaxis

35. Prevention Pre-op PX Optimize nutrition Temperature control Control glucose Stop smoking

36. Prevention Pre-op Theater/Staff Antiseptic skin preparation should be standardized Keep fingernails short; do not wear artificial nails. Scrub hands and forearms as high as the elbows for at least 2-5 minutes with appropriate antiseptic . Liquid -resistant sterile surgical gowns and sterile gloves are to be worn by scrubbed surgical team members. Routine exclusion of personnel colonized by organisms/ ppl with wounds

37. Prevention Intra-op Microbial Asepsis and antisepsis Avoid spillage

38. Prevention Intra-op Surgical tech Careful tissue handling Complete debridement Eliminate dead space Hematoma/ seroma Monofilament sutures Justified drain use

39. Prevention Intra- op PX Supplemental 02

40. Prevention Post- op Microbial Protect incision for 48-72hrs with dressing insitu Remove drains ASAP Avoid post op bacteremia

41. Prevention Post- op PX Early enteral nutrition Supplemental O2 Tight glucose control

42. Follow Up The US Centers for Disease Control (CDC) definition insists on a 30-day follow-up period for non- prosthetic surgery and 1 year after implants There are scoring systems for the severity of wound infection, which are particularly useful in surveillance and research. Examples are the Southampton and ASEPSIS systems

43. - Southampton scoring sys 0 Normal healing I Normal healing with mild bruising or erythema Ia  Some bruising Ib  Considerable bruising Ic  Mild erythema II Erythema plus other signs of inflammation IIa  At one point IIb  Around sutures IIc  Along wound IId  Around wound III Clear or haemoserous discharge IIIa  At one point only (􏰀 2 cm) IIIb  Along wound (> 2 cm) IIIc  Large volume IIId  Prolonged (> 3 days) IV Major complication Pus IVa  At one point only ( 􏰀<2 cm) IVb  Along wound (> 2 cm) V Deep or severe wound infection with or without tissue breakdown

44. criteria points A dditional treatment antibiotics 10 I $ D under LA 5 Debridement under GA 10 S erous exudate 0-5 E rythema 0-5 P urulent dx 0-10 S eparation of deep tissues 0-10 I solation of bacteria/microbes from wound 10 S tay in hosp >14days 5

45. Conclusion The knowledge of surgical site infection helps in regulating morbidity and mortality associated with surgical wounds. T he goal of every surgeon is to prevent wound infections; however, when they arise treatment is individualized to the patient, the wound, and the nature of the infection .

46. REFERENCES Greg J, Beilman , David; surgical infections; schwartz principles of surgery, 10 th Ed (pg 135- 55) Norman S.W, P. Ronan, Andrew W; Bailey & Love’s Short Practice of Surgery; surgical infections; 27 th Ed. (Pg 43-55) Charlse H.T, Kevin CC, Arun K.G; Grabb and Smith’s Plastic Surgery; Wound Healing: Normal and Abnormal; 7 th Ed (Pg 21-2) Hemant S, Francisco T, Amy LF; Wound infection Clinical presentation; General Surgery; Medscape ;