Surgical Site Infections

SURGICAL SITE INFECTION (SSI) Norhaimaz Mohd Manoor Cardiothoracic Dept HSAJB

INTRODUCTION Surgery – since 600BC Before the mid-19th century, surgical patients

commonly developed postoperative “irritative fever,” Followed by purulent drainage from their incisions, Overwhelming sepsis, and often death

Late 1860s, after Joseph

Lister introduced the principles of antisepsis, postoperative infectious morbidity ↓ ↓ Introduce concept of STERILITY- using a solution of carbolic acid.

Modern Surgery Advances in infection control practices include improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis Prove less infection

SSIs remain a substantial cause of morbidity and

mortality Explained by the emergence of antimicrobial-resistant pathogens ↑patients elderly; chronic, debilitating, or IC ↑ prosthetic implant and organ transplant operations Complex surgery

Advances in surgery and anaesthesia have resulted

in patients who are at greater risk of SSI being considered for surgery.

Increase morbidity

Outcome

Increase mortality Increase length of stay Increase cost

Outcomes (cont.) 2%‐5% patients undergoing inpatient surgery

(US,UK) Outcomes (effect on quality of life).

↑ hospital stay ; ~ 7‐10 days additional post-op stays 2‐11 times higher risk of death 70% of deaths among patients with SSI are directly

attributable to SSI. financial burden to healthcare providers. Add ￡ 814 ￡ 6626 (type of surgery and the severity)

CTW Jan – April 09 (Readmission for SSIs)

Surgical Site Infections (SSIs) In 1992, Centers for Disease Control and Prevention (CDC) had change terms of Surgical wound infections to surgical site infections (SSI),

Infections that occur in the wound created by an invasive surgical procedure

Cross-section of abdominal wall depicting CDC classifications of surgical site infection

Prevention Majority are preventable and measures can be taken

to reduce risk of infection. pre-, intraand postoperative phases of care

It is important that we adhere to best practice to

prevent and manage SSIs.

Risk Factors & Recommendation

1) Mangram, MD at al GUIDELINE FOR PREVENTION OF SURGICAL SITE INFECTION, 1999 (CDC) 2) Guideline Development Group; Surgical site infection prevention and treatment of surgical site infection, National Collaborating Centre for Women’s and Children’s Health (NICE) October 2008

Risk Factors (Patient caracteristics)

Age (unmodifiable) Nutritional status Diabetes Smoking Obesity Coexistent infections at a remote body site Colonization with microorganisms Altered immune response Length of preoperative stay

Risk Factors (Unmodifiable) Age significant independent predictor in adults until age 65 (a direct linear trend of increasing

risk of SSI) > 65 (an inverse linear trend of SSI)

Risk Factors (Modifiable) Underlying illness patients with an ASA score of > 3 Diabetes Control serum glucose levels  Study: patients who underwent CABG :increasing levels of HbA1c and SSI rates.  Recommendation: reduce HbA1c levels to 7% before surgery (UK) 

Radiotherapy and steroid use (controversial)

Underlying illness (cont.) Malnutrition & low serum albumin. Controversial Study: preoperative protein calorie malnutrition is not an independent predictor of mediastinitis after CABG Recommendation: postoperative nutritional support major oncologic operations,  after many operations on major trauma victims,  or in patients suffering a variety surgical complications that preclude eating or that trigger hypermetabolic state. 

Risk Factors (Modifiable) vasoconstrictive effects & reduced oxygen carrying capacity

Nicotine : delays 10 wound healing

PVDs increase SSI

Study: Smoking, duration of smoking and number of cigarettes smoked increased risk of SSI. Study: current cigarette smoking, independent risk factor for sternal and/or mediastinal SSI following cardiac surgery (large prospective study)

Risk Factors (Modifiable)

Recommendations ENCOURAGE SMOKING CESSATION WITHIN 30 DAYS BEFORE PROCEDURE

Risk Factors (Modifiable) Obesity increased risk of SSI. Increase dosing of prophylactic antimicrobial agent for morbidly obese patients Wound classification Study: risk of infection increases with level of wound contamination. developed by the National Academy of Sciences 1960s distinguishes 4 levels of risk,

Surgical wound classification

 Clean:  no inflammation is encountered in a surgical procedure,  without a break in sterile technique,  and during which the respiratory tract, alimentary or GU tracts are not entered.  Clean-contaminated:  the respiratory, alimentary, or genitourinary tract is entered under controlled conditions  with no contamination encountered.  Contaminated:  a major break in sterile technique  or gross spillage from the gastrointestinal tract,  or an incision in which acute, non-purulent inflammation is encountered.  Open traumatic wounds > 12–24 hours old  Dirty or infected:  the viscera are perforated  or when acute inflammation with pus is encountered (for example, emergency surgery for

faecal peritonitis),  and for traumatic wounds where treatment is delayed,  faecal contamination, or devitalised tissue is present.

Risk Factors (Modifiable) Prolonged preoperative hospital stay Study: patient characteristic associated with increased SSI risk. likely d/2 severity of illness and co-morbid conditions requiring inpatient work-up before the operation.

Recommendations Keep preoperative hospital stay as short as possible (USII)

ZZZ…

Risk Factors (Operation caracteristics)

Recommendations (Operative caracteristics) Preoperative  Preparation of the patient  Preoperative antiseptic showering  Preoperative hair removal  Antibiotic prophylaxis  Hand/forearm antisepsis for surgical team members Intraoperative  Operating room environment  Surgical attire and drapes  Asepsis and surgical technique Postoperative incision care

RecommendationsPreoperative Preparation of the patient Preoperative antiseptic showering Preoperative hair removal Antibiotic prophylaxis Hand/forearm antisepsis for surgical team members

RecommendationsPreoperative

Preparation of the patient identify and treat all infections remote to the surgical site before elective operation (US) postpone elective operations on patients with remote site infections until the infection has resolved (US IA)

RecommendationsPreoperative

Preoperative antiseptic showering decreases skin microbial colony counts Study: measure to reduce the rate of SSI chlorhexidine vs plain detergent or soap (no diferent) RecommendationsAdvise patients to shower or bathe with an antiseptic agent on at least the night before the operative day. (US IB) using soap, either the day before, or on the day of, surgery. (UK)

RecommendationsPreoperative

Preoperative hair removal adequately view or access the operative site presence of hair = ↑ risk of microbial contamination shaving using razors: micro-abrasions of the skin (↑ number of microorganisms colonising) If indicated, minimise damage to the skin Study; immediately before the operation:3.1% ;  Shaving within 24 hours pre-op: SSI rates (7.1%);  performed >24 hours, the SSI rate > 20%. 

RecommendationsPreoperative hair

Do not remove hair routinely preoperative unless the

hair at or around the incision site will interfere with the operation (US ,UK) If hair is removed, remove immediately before the operation, preferably with electric clippers –single use head (US, UK) Do not use razors for hair removal, because they increase the risk of SSI. (UK)

RecommendationsPreoperative

Antibiotic prophylaxis Used to prevent SSIs since 1969 administration of AP up to 2 hours preoperatively is a/w lowest rates of infection receiving AP 0–2 hours : lowest SSI rate each successive hour delayed after incision: higher rates SSIs unexpected contamination : should be converted into a treatment regime.

RecommendationsAntibiotic prophylaxis

Antimicrobial prophylaxis Administer only when

indicated (UK, US) Give antibiotic prophylaxis to patients before: clean surgery involved prosthesis or implant clean-contaminated surgery contaminated surgery. (UK)

Timing Administer <1 hour before incision (US); single dose of IV on starting anaesthesia (UK)

RecommendationsAntibiotic prophylaxis

Choice basis of surgical procedure, most common pathogens causing SSI for a specific procedure, and published recommendations (US) Duration of therapy Stop prophylaxis within 24 hours; for cardiac surgery, stopped within 48 hours repeat dose when the operation is > half-life; excessive blood loss or prolonged op. (UK, US)

Recommendations-Patient theatre wear No study specific theatre wear that is appropriate for the

procedure and clinical setting provides easy access (for operative site, placing devices) Consider also the patient’s comfort and dignity. (UK)

Recommendations-Staff preparation

All staff should wear specific non-sterile theatre wear

in areas where operations are carried out. (UK) Movement of staff in and out of these areas should be kept to a minimum. (US, UK) Operating team staff should remove hand jewellery, artificial nails and nail polish before operations (US, UK)

Recommendations-Staff preparation

Hand/forearm antisepsis for surgical

team members

Keep nails short and do not wear artificial nails. Perform surgical scrub for at least 2 to 5 minutes using

an appropriate antiseptic Scrub the hands and forearms up to the elbows After scrub, keep hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and don a sterile gown and gloves

RecommendationsIntraoperative Operating room environment Surgical attire and drapes Asepsis and surgical technique

RecommendationsAntiseptic skin

Apply in concentric circles moving toward the

periphery. (US) Area large enough to extend the incision or create new incisions or drain sites (US II) Prepare the skin at the surgical site immediately before incision (UK) If diathermy used, ensure its dried by evaporation and pooling of alcohol-based preparations is avoided. (UK)

RecommendationsIntraoperative

Diathermy used for coagulating bleeding vessels and cutting tissues. may cause more tissue damage: reduce incidence of haematoma. Study: diathermy vs conventional scalpel or scissors (controversial, no different) Recommendations- Do not use diathermy for surgical

incision to reduce the risk of SSIs. (UK)

Recommendations- Asepsis and surgical technique Aseptic technique throughout procedure; Placing devices (e.g., central venous catheters), spinal or epidural anesthesia catheters, or when dispensing and administering IV drugs. US

Drains; use a closed suction drain; separate incision distant from the operative incision. Remove the drain as soon as possible. US

Recommendations- Asepsis and surgical technique Maintaining patient homeostasis Warming Oxygenation Perfusion

RecommendationsPostoperative

Postoperative incision care  Protect with a sterile dressing for 24 -48 hours postoperatively an incision that has been closed primarily. (US, UK)  Wash hands  When an incision dressing must be changed, use sterile technique. (US, UK)  Patients may shower safely 48 hours after surgery. (UK)  Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms. (US)

RecommendationsInformation for patients

When, how and what information should be provided

for patients for the prevention of surgical site infection? Offer patients and carers clear, consistent information and advice throughout all

stages of their care. include the risks of SSIs, what is being done to reduce them and how they are managed. (UK)

Common symptoms of SSI Redness & pain around the area of surgery Drainage of cloudy fluid from surgical wound Fever

Conclusions Have patient stop smoking. Even 2 weeks helps. Have patient shower with chlorhexidine the evening

before and morning of operation Prevent hyperglycemia Prevent fall in body temperature Optimize oxygen tension Don’t shave operative site Antibiotics – right antibiotic, on time, for proper duration, dosed appropriately

Thank you