Surgical Site Infection updated by Manojit(MS)

Updated SSI

1. SURGICAL SITE INFECTION - Manojit Sarkar 1 st year Jr General surgery Unit-II

2. Why this topic? SSI is MOST COMMON hospital acquired infection in surgical patients. 3 rd most common hospital acquired infection. Preventable Prolong the hospital stay (7.3 days) Expenditure Over one-third of postoperative deaths Poor scar, persistent pain and itching, restriction of movement and a significant impact on emotional wellbeing

3. 3 HISTORY

4. Alexander Fleming 5 The discovery of the antibiotic penicillin is attributed to Alexander Fleming in 1928, but it was not isolated for clinical use until 1941 by Florey and Chain. Since then, there has been a proliferation of antibiotics with broad-spectrum activity and antibiotics today remain the mainstay of antimicrobial therapy. Ref: Bailey & Love’s Short Practice of Surgery , 2 7 th Edition.

5. What is SSI? Surgical site infections (SSIs) are infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure.

6. classification

7. According to depth of wound infections

8. Superficial incisional surgical site infections Infection occur s within 30 days of procedure Involve skin or subcutaneous tissue At least one of the followings: purulent drainage +/- organisms isolated aseptically from fluid or tissue of superficial incision Superficial incision that is deliberately opened by the surgeon & is culture positive or not cultured Patient has one of the followings signs/symptoms(pain/ tenderness,localised swelling,redness,temparature

9. Superficial Incisional R edn e ss Pain S w el l i n g Heat Discharging pus

10. Deep incisional surgical site infections Infection occur within 30 days of procedure (or one year in the case of implants) Involve deep soft tissues, such as the fascia and muscles. At least one of the followings: purulent drainage from deep incision, signs of infection spontaneously dehisces or opened by surgeon & is culture positive or not cultured Fever >38 degree c,localized pain or tenderness an abscess or other evidence of infection found on direct exam,during invasive procedure,by HPE,by imaging test Diagnosis of deep ssi by surgeon or attending physician

11. Deep Incisional Wound Gapping Fever Pain Discha rg e

12. Organ or space Surgical site Infection 30 days no implant or 1 year with implant Any part is involved which was opened or manipulated other than the incision At least one of the followings: purulent drainage from deep incision, signs of infection Organism isolated from an aseptically obtained culture of fluid or tissue in the organ/space an abscess or other evidence of infection found on direct exam,during invasive procedure,by HPE,by imaging test Diagnosis of deep ssi by surgeon or attending physician

13. Organ/Space SSI Fever Pain Ano r e xia Discharge through drain Imaging study

14. E ar l y Infection presents within 30 days of procedure Intermediate Occurs between one and three months L a t e Presents more than three months after surgery According to time

15. According to Minor Wound infection is described as minor when there is discharge without cellulitis or deep tissue destruction MAJOR When there is pus discharge with tissue breakdown , Partial or total dehiscence of the deep fascial layers of wound or if systemic illness is present.

16. The risk is also m i croorganism related to the amount of contamination with s which is called “class” of the operation Surgical wounds classification D e finition Ref:CDC C l ean Operations in which no inflammation is encountered and the respiratory, alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre technique. eg:hernioplasty,thyroidectomy,surgeries of brain,joints,heart & transplant. Clean-contaminated Operations in which the respiratory, alimentary or genitourinary tracts are entered but without significant spillage. Eg:appendectomy,GJ,pancratic & biliary surgery Contaminated Operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound. Examples include gross spillage from a hollow viscus during the operation or compound/open injuries operated on within four hours Dirty Operations in the presence of pus, where there is a previously perforated hollow viscus, or compound/open injuries more than four hours old. Eg:Abscess,perforated viscous with peritonitis,fecal contamination

17. Infection rate (before & after prophylaxis)

18. Wound ASSESSMENT SCORE SYSTEM

19. SEPSIS 3.0 Ref: INTERNATIONAL GUIDELINES FOR MANAGEMENT OF SEPSIS & SEPTIC SHOCK,2016 SEPSIS 2(old)

20. Pathogenesis of surgical site infection Contaminati on E nd o g e n ous infection E x o g e n ous infection Hae m at o g e n o us spread Staph aur eus E n t e r oba c t e riaceae and anaerobes Proliferation of bacteria Induce i n flamm a ti on – signs appear Identified or unidentified Self resolving -> resolve by treatment -> sepsis and death

21. Risk Factors for Development of Surgical Site Infections Patient factor Local factor Microbial factor

22. Patient factors Older age Immunosuppression Obesity Diabetes mellitus Chronic inflammatory process Malnutrition Peripheral vascular disease Smoking Anemia Radiation Steroid use

23. Local factors Poor skin preparation Contamination of instruments Inadequate antibiotic prophylaxis Prolonged procedure Site and complexity of procedure Local tissue necrosis Hypoxia Hypothermia

24. Microbial factors Prolonged hospitalization Toxin secretion Resistance to clearance (e.g., capsule formation)

25. Prevention of surgical site infections

26. Phases: Pre op phase Intra op phase Post op phase

27. Pre operative Phase Pre op Shower With soap (CHLORHEXIDINE SOAP) Day before or on thev day of surgery(8-12 hrs prior) Nasal decontamination: Consider nasal mupirocin Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

28. Pre operative Phase Shavi ng: Limited to the area of surgery Day of surgery Disposable razor Depilation cream Electric clippers with single use Clipping Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

29. Pre-operative Shaving/Hair Removal Method of hair removal Razor = 5.6% SSI rates Depilatory = 0.6% SSI rates Timing of hair removal Shaving immediately before Shaving  24 hours before Shaving >24 hours before = 3.1% SSI rates = 7.1% SSI rates = 20% SSI rates 29 Ref :CDC

30. Problems of Shaving Pain Allergy Infection risk!

31. Pre operative Phase Patient theatre wear: Give patients specific theatre wear that is appropriate for the procedure and clinical setting, and that provides easy access to the operative site and areas for placing devices, such as intravenous cannulas. Take into account the patient's comfort and dignity Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

32. Pre operative Phase Theatre staff ’S Dress Non-S terile & clean Cap & Mask Shoes Goggles Staff leaving the operating area : minimum movements in & out of the operating area Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

33. Pre operative Phase Mechanical bowel preparation: Do not use mechanical bowel preparation to reduce ssi Hand jewellery , artificial nails & polish The operating team should remove hand jewellery or artificial nails or polish Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

34. Pre operative Phase Hand washing Betadine/Chlorhexidine No need for soap/brush 5 minute ritual 2 minute between cases/hand scrub

35. Pre operative Phase Antibiotic prophylaxis 1 hour before incision Before in cision ! Additional dose: – if prolonged operation Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

36. Antibiotic prophylaxis Give antibiotic prophylaxis to patients before: clean surgery involving the placement of a prosthesis or implant clean-contaminated surgery contaminated surgery . Do not use antibiotic prophylaxis routinely for clean non- prosthetic uncomplicated surgery. Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis. Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia . F o r op e r a ti o n s in wh i ch a t ou r nique t is use d gi v e prophylaxis earlier Ref: NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2 018-19 . ) 36

37. Suggested prophylactic regimens for operations at risk Ref: Bailey & Love’s Short Practice of Surgery , 2 7 th Edition

38. Importance of Timing of Surgical Antimicrobial Prophylaxis (AP ) Prospective study of 2,847 elective clean and clean-contaminated procedures Early AP (2-24 hrs before incision): Postop AP (3-24 hrs after incision): Periop AP (< 3 hrs after incision): Preop AP (<2 hrs before incision): 3 . 8 % 3. 3 % 1. 4 % 0. 6 % Ref :CDC

39. Intra operative Phase Sterile Gown & Gloves Water resistant gowns Double glove technique Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

40. Intra operative Phase Patient skin Preparation Iodine/Chlorhexidine Allow it to dry & avoid spillage to diathermy pad Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

41. Intra operative Phase Incision drapes Use iodophor impregnated sticky drapes unless the patient has an iodine allergy Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

42. Intra operative Phase Diathermy Don’t use diathermy for surgical incision to reduce SSI Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

43. Intra operative Phase Patient Homeostasis Avoid Hypothermia Warm fluids for infusion and for lavage Warm blankets Warm mattress Monitor temperature every 30 min during surgery and post op Avoid Hypoxia Post operative mask O2 / monitor Spo2 Avoid hypotension Infuse adequate fluids Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

44. Intra operative Phase Theatre discipline Sterile & Quiet environment Avoid to & fro movement Ensure sterility of equipments & Theatre Laminar airflow/Filters Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

45. Parameters for Operating Room Ventilation Temperature : 68 o -73 o F, depending on normal ambient temp 30%-60% from “clean to less clean” Relative humidity : Air movement : areas Air changes : > 15 total per hour > 3 outdoor air per hour Ref: American Institute of Architects

46. Laminar Air flow Ref: American Institute of Architects

47. Intra operative Phase Wound irrigation & intracavitary lavage: Don’t give to reduce ssi Antiseptics & antibiotics before wound closure: Under clinical research trial Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

48. Intra operative Phase Wound s closure methods: Consider using sutures rather than staplers to reduce the superficial wound dehiscence Consider using triclosan-coated suture especially in pediatric surgery to reduce ssi Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

49. Intra operative Phase Wound dressing : Cover surgical incisions with appropriate interactive dressings at the end of operation Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

50. Post-operative measures 52 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 48 hours after surgery. Advise patients that they may shower safely 48 hours after surgery. Use tap water for wound cleansing after 48 hrs if the surgical wound has separated or has been opened surgically to drain pus Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

51. Post-operative measures 53 DON’T use Topical antimicrobial agents for wound healing by primary intention Dressings for wound healing by secondary intention Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions. Use an appropriate interactive dressing. Ref:NICE Guideline on Prevention an d treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

52. Post-operative measures Antibiotic treatment of surgical site infection and treatment failure When surgical site infection is suspected (i.e. cellulitis), either de novo or because of treatment failure, give the patient an empirical antibiotic that covers the likely causative organisms. Debridement : Don’t use eusol/gauze or enzymatic treatments for debridement to reduce ssi Ref:NICE Guideline on Prevention and treatment of surgical site infection , ( National Institute for Health and Clinical Excellence, 2018-19.)

53. management of SSI Surveillance Drainage of pus Culture and sensitivity MRSA VRE ESBL strains Debridement Antibiotics Removal of Implant

54. T r e a tme n t

55. Management of Incisional surgical site infection Removal of sutures with drainage of pus Pus sent for c/s Debridement and open wound care D elayed primary or secondary suture once wound shows signs of healing by healthy granulation tissue

56. Take Home Message Types of ssi Sepsis 3.o Nice guidelines for prevention of ssi Measures taken Antibiotic prophylaxis MANAGEMENT OF ssi

57. Ssi prevention-animated video clip

58. THANK YOU! References : Bailey & Love’s Short Practice of Surgery , 2 7 th Edition Sabiston Textbook of Surgery NICE guidelines of SSI WHO guidelines of SSI SRB manual of Surgery,6 th ed