SURGICAL SITE INFECTIONS.pptx

For surgical residents presentation

1. SURGICAL SITE INFECTIONS By Dr. Olofin. K E

2. OUTLINE INTRODUCTION DEFINITION OF TERMINOLOGIES HISTORICAL PERSPECTIVE EPIDEMIOLOGY CLASSIFICATION PATHOGENESIS AND SURGICAL MICROBIOLOGY CLINICAL FEATURES FACTORS INFLUENCING SSI’s CLINICAL ASSESSMENT MANAGEMENT PREVENTION CONCLUSION

3. introduction A surgical site infection (SSI)refers to the presence of pain at a surgically created wound, which is accompanied by erythema , induration and local tenderness or presence of purulent discharge at wound site. They refer to infections of the tissues, organs, or spaces exposed by surgeons during performance of an invasive procedure

4. definitions Colonization Bacteria present in a wound with no signs or symptoms of systemic inflammation Usually less than 10 5 cfu /gram of tissue Contamination Transient exposure of a wound to bacteria Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy

5. Infection Systemic and local signs of inflammation Bacterial counts ≥ 10 5 cfu /gram of tissue Purulent versus nonpurulent Surgical wound infection is SSI

6. Definition of SSI’s Infection occurring anywhere along the surgical tract after a surgical procedure anytime from 0 – 30 days post op. OR up to 1 year post op. if a foreign material was used(prosthesis).

7. Historical perspective Before the late 19 th Century, serious infections among hospitalized patients were rampant and the morbidity & mortality were astounding. Nearly all traumatic & surgical wound healing was accompanied by inflammation & suppuration. Galen; 130 – 200 AD “Suppuration often heralded recovery ”

8. Theodoric of Cervia , Pare & Guy de Chuliac disagreed with Galen’s dictum. 1861, Ignac Semmelweis ; Washing of hands → ↓maternal mortality! 1867, Louis Pasteur showed that infection is caused by microbes foreign to the infected. 1867, Joseph Lister introduced antisepsis

9. Epidemiology Incidence of SSI varies depending on the type of surgical procedure carried out and the class of surgical wound and maybe as high as 20%. SS-Infections are the 2 nd most common nosocomial infections. It also represents the commonest nosocomial infection amongst surgical patients accounting for 38% of NI’s.

10. Epidemiology Causes substantial morbidity and mortality viz : - post-op length of hospital stay by 7-10days - Increases hospital charges substantially in affected patients - Death is directly linked to SSI in >75% of patients with SSI who die in the post-op period.

11. Classification Classification of SSI’s could be based on Depth of Tissue involved Etiology Time Severity

12. classification

13. Classification contd

14. Classification contd Etiology a) Primary The wound is the primary site of infection. b)Secondary Infection arises following a complication that is not directly related to the wound.

15. Classification contd Time a) Early Infection presents within 30 days of procedure b) Intermediate Occurs between 1-3 mths c) Late Presents >3mths post-surgery

16. Classification contd Severity a) Minor - Discharge without cellulitis /deep tissue destruction b) Major - Pus discharge + tissue breakdown , - Partial or total dehiscence of the deep fascial layers - Presence of Systemic illness

17. Pathogenesis Bacterial dose Virulence Impaired host resistance

18. Microbiology

19. Clinical features Erythema Discharge Superficial From drain(s) Pain Fever Tenderness Delayed return of bowel sounds Other inflammatory changes

20. FACTORS INFLUENCING DEVELOPMENT OF SSI’S Patient factors Multiple Co-Morbidities (Diabetes ,CKD, P.VasDx ) Nicotine use Immunosuppression (Steroid use, Malignancy) Malnutrition (Obesity, Undernutrition ) Hospital stay  Nares colonization with S. aureus Transfusion.

21. Pre-Op factors Preoperative antiseptic showering Preoperative hair removal Patient skin preparation in the operating room Preoperative hand/forearm antisepsis Antimicrobial prophylaxis

22. Pre-Op factors Preoperative hair removal  S having : immediately before the operation: SSI rates 3.1% shaving within 24 hours preoperatively: 7.1% having performed >24 hours: SSI rate > 20%.  Hair removing creams: lower SSI risk than shaving or clipping hypersensitivity reactions

23. Prophylactic antibiotics Class 1 = Clean Class 2 = Clean contaminated ( Prophylactic antibiotics indicated) Class 3 = Contaminated( Prophylactic antibiotics indicated) Class 4 = Dirty infected ( Therapeutic antibiotics indicated)

24. ABX Once the incision is made, antibiotic delivery to the wound is impaired. Must give before incision!

25. Intra-Op factors Operating room environment Surgical attire and drapes Asepsis and surgical technique

26. Intra-Op factors Operating room environment Ventilation - Positive pressure with respect to corridors and adjacent areas. Environmental surfaces - Rarely implicated as the sources of pathogens important in the development of SSIs. - Important to perform routine cleaning of these surfaces  Conventional sterilization of surgical instruments - Inadequate sterilization of surgical instruments has resulted in SSI outbreaks

27. Intra-Op factors Surgical attire and drapes  The use of barriers: - patient : minimize exposure to the skin, mucous membranes, or hair of surgical team members - surgical team members : protect from exposure to blood and blood-borne pathogens. Asepsis and surgical technique Rigorous adherence to the principles of asepsis by all scrubbed personnel Excellent surgical technique: reduce the risk of SSI.  Drains: increase incisional SSI risk.

28. Post-Op factors Incision care P rimary Closure, Delayed Primary Closure, wound left open to heal by second intention . Haematoma / Seroma formation Foreign body Presence of non-viable tissue

29. Wound assessment The most common Surgical wound assessment scores used include: ASEPSIS SCORE SOUTHAMPTON SCORE

30. ASEPSIS SCORE A DDitional Treatment A ntibiotics D rainage under L.A. D ebridement under G.A. S erous Discharge E rythema P urulent exudate S eparation of wound I solation of pathogen S tay in hospital > 2 weeks

31. ASEPSIS SCORE

32. Southampton Score

33. Management of SSI’s Source control Incision and Drainage Percutaneous Surgical Frequent wound dressing Débridement and delayed primary closure Antibiotic therapy.

34. Prevention Antisepsis Asepsis Antibiotics Manipulation of host factors to minimize infection .

35. Pre-op precautions Pre op warming Cessation of smoking Adequate nutrition Plasma glucose control throughout Supplemental oxygen

36. Intra-op precautions Strict maintenance of asepsis Double gloving, strategic positioning Minimal handling of tissue Avoid desiccation, keep tissue warm... Ensure adequate tissue perfusion Ensure sufficient haemostasis

37. Intra-op precautions contd Avoid dead space Remove all necrotic/devitalized tissue completely Justified drain use Delayed primary closure when indicated

38. Post-op Precautions Keep surgical incision(s) protected Continue effective antibiotic therapy Remove all drains as soon as practicable! Resume enteral nutrition as soon as permissible Supplemental O 2 Keep patient warm

39. Conclusion

40. THANKS FOR LISTENING!