Surgical Site Infections, pathophysiology, and prevention.pptx

A short overview presentation for medical allied health care professionals and under graduate medical courses

1. Surgical Site Infections

2. Surgical Site Infections infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure leads to: increased morbidity increased mortality increased hospital duration increased cost

3. Surgical Site Infections Most surgical site wound infections originate from endogenous flora typically found on mucous membranes, skin, or hollow viscera causes are diverse direct contact airborne transmission contamination with endogenous microbes Susceptibility may be influenced by various factors

4. Surgical Site Infections Microorganism are normally prevented from causing infection in tissues Mechanical: intact epithelium Chemical: low gastric pH Humoral: antibodies , complement system , and opsonins Cellular: phagocytic cells, macrophages, PMN, killer lymphocytes Surgical intervention with existing comorbid condition may compromise these protective factors

5. Types of Surgical Site Infections

6. Superficial Incisional SSI Occurs within 30 days after an operative procedure Only involves skin and subcutaneous tissue of the incision

7. Superficial Incisional SSI Patient should have at least one of the ff: Purulent drainage from superficial incision Organisms isolated from an aseptically-obtained culture of fluid/tissue from the superficial incision At least one of the ff signs and symptoms pain/tenderness localized swelling, redness, heat Superficial incision that is deliberately opened by a surgeon unless incision culture is negative Diagnosis of superficial incisional SSI by the surgeon

8. Deep Incisional SSI Occurs within 30 - 90 days after an operative procedures if no implant is left in place within 1 year if implant is in place Only involves deep soft tissues of the incision (fascial and muscle layers)

9. Deep Incisional SSI Patient should have at least one of the ff: Purulent drainage from deep incision but not from organ/space component of surgical site Deep incision that spontaneously dehisces or is deliberately opened by a surgeon Fever Localized pain/tenderness Abscess or other evidence of infection involving deep incision found on direct examination, reoperation, histopathologic, radiologic examination Diagnosis of superficial incisional SSI by the surgeon

10. Organ/Space SSI Occurs within 30 days after an operative procedures if no implant is left in place within 1 year if implant is in place I nvolves any part of the body other than the incision which was ope ned or manipulated during the operation

11. Organ/Space SSI Patient should have at least one of the ff: Purulent drainage from a drain that is placed through a stab wound into the organ/space Organisms isolated from an aseptically-obtained culture of fluid or tissue in the organ/space An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination Diagnosis of an organ/space SSI by a surgeon/attending physician

12. Sepsis is the most common cause of death in noncoronary critical care units and the 11th most common cause of death overall in the United States, with a mortality rate of 10.3 cases per 100,000 population.

13. Postoperative Fever 5 Ws of Postoperative Fever WIND Atelectasis < 48 hrs Pneumonia >48 hrs WATER Urinary Tract Infection 3-5 (3) days WALK Deep Vein Thrombosis 4-6 (5) days WOUND Surgical Site Infections 5-7 (7) days WONDER DRUGS Medications >7 days

14. Risk Factors of SSI Patient factors Environmental factors Treatment factors Comorbid illnesses (DM, PAOD, Hypocholesterolemia, Anemia, Chronic Inflammatory Disease, Skin Disease in Area of Infection) Nutritional state (Malnutrition, Obesity) Avoidable factors (Preoperative shaving, Extended Preoperative Admission) Inadequate sterilization I nadequate disinfection or skin antisepsis Emergency procedure failure to obliterate dead space hypothermia inadequate antibiotic prophylaxis surgical drains poor hemostasis tissue trauma prolonged operative time

15. Prevention of SSIs Pre-operative

16. Parenteral Antimicrobial Prophylaxis give antibiotic prophylaxis once an incision is made, antibiotic delivery to the wound is impaired thus antibiotics must be given before skin incision

17. Parenteral Antimicrobial Prophylaxis Preoperative dose timing: within 60 mins before skin incision within 120 mins for vancomycin Single dose is adequate Redosing (to ensure adequate concentration): if duration of surgery exceed 2 half-lives of antimicrobial excessive blood loss

18. Parenteral Antimicrobial Prophylaxis Principles of Antibiotic Prophylaxis Select an agent with activity against organisms commonly found at the site of surgery Administer the initial dose of the antibiotic within 30 minutes prior to incision Redose the antibiotic during long operations based upon the half-life of the agent to ensure adequate tissue levels Limit the antibiotic regimen to no more than 24 hours after surgery for routine prophylaxis

19. Non-Parenteral Antimicrobial Prophylaxis Do not apply antimicrobial agents to the surgical incision fo prevention of SSI ointments solutions powders Consider use of triclosan-coated sutures for prevention of SSI

20. Glycemic Control Pre-operative glycemic control target glucose level: < 200 mg /dL in patients with or without diabetes

21. Prevention of SSIs Intra-operative

22. Skin Preparation Advise patients shower or full bath night prior operative day use of soap or antiseptic agent Hair removal using clippers Razors may create nicks in the skin fostering bacterial growth Intraoperative skin preparation with alcohol-based antiseptic agent

23. Operating Theatre Pre-op washing of hands Minimal stay Sepsis/antisepsis Standardized operative technique Proper sterile techniques Sterile caps, masks, gowns, gloves Sterilized drapes, instruments Gentle tissue handling, appropriate suture materials, avoiding dead space Wearing Surgical Scrubs outside Operating room Can lead to Contamination

24. Proper Operating Room Attire

25. Operating Theatre Layout At least 7x7x5.5 meters to accommodate equipments, intraoperative imaging, and patient monitoring Environment Temperature: 18-24C Ventilation: maintain negative pressure to minimize spread of contaminants; 6-10 total air exchanges per hour Humidity: 20-60%; low humidity facilitate spread of airborne disease vectors

26. Lay out Sample or an Operating Room

27. Operating Theatre Environment Air Filters : through HEPA filter with filtration level up to 0.3 microns and 99.97% efficiency with pre filters in the system Air flow: laminar flow, low turbulence downward displacement air flow towards operation zone

28. Prevention of SSIs Post-operative

29. Incision Care Postoperative incision care based on wound closure Primary closure: usually covered with sterile dressing for 24-48 hrs Secondary: packed with sterile moist gauze and covered with sterile dressing Tertiary: incision is packed with sterile dressing

30. Incision Care Change of dressing daily Use an aseptic non-touch technique for changing or removing surgical wound dressings Postoperative cleansing Sterile saline for wound cleansing up to 48 hrs after surgery May have full bath 24- 48 hrs after surgery

31. Ideal Ward setting Avoid overcrowding of wards by keeping centers of bed at least 8 feet apart one wash hand basin per room patients harboring transmissible disease should be put on isolated rooms

32. Sources Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 11e. McGraw-Hill Education; 2019. National Collaborating Centre for Women's and Children's Health (UK). Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. London: RCOG Press; 2020 Zabaglo M, Leslie SW, Sharman T. Postoperative Wound Infections. [Updated 2024 Mar 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan Nourian M, Baker R, Fader J. Operating Theatre Setup. Vanderbuilt University Medical Center; April 2023 Hamed H Al-Ammari et Al. Influence of Surgical Scrubs Outside the Operation Theater on Post Operative Infection. Indian Anesthesia journal; March 2024 Blom AW, Barnett A, Ajitsaria P, Noel A, Estela CM. Resistance of disposable drapes to bacterial penetration. J Orthop Surg (Hong Kong). 2007 Dec;15(3):267-9. doi: 10.1177/230949900701500303. PMID: 18162666. Toney-Butler TJ, Gasner A, Carver N. Hand Hygiene. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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