Surgical Site InfectionsSurgical Site Infectionswhat an enigma?what an enigma?

Moderated by :Moderated by :

Dr Nasser Hammoud M.D ,FACSDr Nasser Hammoud M.D ,FACS

Presented byPresented byAli Haydar M.D PGY3 HHUMC General Ali Haydar M.D PGY3 HHUMC General

Surgery DepartmentSurgery Department

Infection

Infection is defined by:Infection is defined by:

1.1. Microorganisms in host tissue or Microorganisms in host tissue or the bloodstream the bloodstream

2.2. Inflammatory response to their Inflammatory response to their presence.presence.

SSI – Definitions

• InfectionInfection– Systemic and local signs of inflammationSystemic and local signs of inflammation– Bacterial counts ≥ 10Bacterial counts ≥ 1055 cfu/mL cfu/mL– Purulent versus nonpurulentPurulent versus nonpurulent– LOS effectLOS effect– Economic effectEconomic effect

• Surgical wound infection is SSISurgical wound infection is SSI

LOS=length of stay.

Surgical Site Infections (SSI)

• Third most common nosocomial infection (14%–Third most common nosocomial infection (14%–16%)16%)

• Most common nosocomial infection among Most common nosocomial infection among surgical patients (38%)surgical patients (38%)

– 2/3 incisional2/3 incisional– 1/3 organs or spaces accessed during surgery1/3 organs or spaces accessed during surgery

• 7.3 additional postoperative days at cost of 7.3 additional postoperative days at cost of $3,152 in extra charges$3,152 in extra charges

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Superficial Incisional SSI

Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Subcutaneous Subcutaneous tissuetissue

SkinSkinSuperficial incisional SSI

Deep Incisional SSIInfection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue (e.g., fascia and muscle layers)

Deep soft tissue Deep soft tissue (fascia & muscle)(fascia & muscle)

Deep incisional SSI

Superficial incisional SSI

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Organ/Space SSIInfection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation

Deep incisional SSI

Superficial incisional SSI

Organ/space SSIOrgan/spaceOrgan/space

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

SSI – Risk FactorsPatient Characteristics

• Age• Diabetes

– HbA1C and SSI– Glucose > 200 mg/dL

postoperative period (<48 hours)

• Nicotine use: delays primary wound healing

• Steroid use: controversial• Malnutrition • Obesity: 20% over ideal body

weight

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

• Prolonged preoperative stay: Preoperative colonization with Staphylococcus aureus: significant association

• Perioperative transfusion: controversial

• Coexistent infections at a remote body site

• Altered immune response

SSI – Risk FactorsOperation Factors

• Duration of surgical scrub• Maintain body temp• Skin antisepsis• Preoperative shaving• Duration of operation• Antimicrobial prophylaxis• Operating room ventilation• Inadequate sterilization of

instruments

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

• Foreign material at surgical site

• Surgical drains• Surgical technique

– Poor hemostasis– Failure to obliterate

dead space – Tissue trauma

Types of SurgeryTypes of Surgery

Clean Clean Hernia repairHernia repair

breast biopsybreast biopsy1.5%1.5%

Clean-Clean-ContaminatedContaminated

CholecystectomyCholecystectomy

planned bowel resectionplanned bowel resection2-5%2-5%

Contaminated Contaminated Non-preped bowel Non-preped bowel resectionresection

5-30%5-30%

Dirty/infected Dirty/infected perforation, abscessperforation, abscess 5-30%5-30%

Preoperative phase (hair removal)

– Do not routinely use hair removal

– Do not use razors for hair removal, as they increase the risk of surgical site infection

– If hair has to be removed, use electric clipperswith a single-use head on the day of surgery

Preoperative phase(antibiotic prophylaxis)

–Give antibiotic prophylaxis before:Give antibiotic prophylaxis before: - clean surgery for the placement of a prosthesis or implant - clean surgery for the placement of a prosthesis or implant - clean-contaminated surgery - clean-contaminated surgery - contaminated surgery - contaminated surgery

–Do not routinely use for clean non-prosthetic uncomplicated Do not routinely use for clean non-prosthetic uncomplicated surgery surgery

–Use local antibiotic formulary and consider adverse effectsUse local antibiotic formulary and consider adverse effects

–Consider prophylaxis on starting anaesthesia, or Consider prophylaxis on starting anaesthesia, or earlier for operations using a tourniquet earlier for operations using a tourniquet

SSI – Wound Classification

• Class 1 = Clean

• Class 2 = Clean contaminated

• Class 3 = Contaminated

• Class 4 = Dirty infected

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Prophylactic antibiotics indicated

Therapeutic antibiotics

THE LENGTH AND DIRECTION OF THE

INCISION • The direction in which wounds naturally heal is from side-

to- side, not end-to-end.• The arrangement of tissue fibers in the area to be dissected

will vary with tissue type.• The best cosmetic results may be achieved when incisions

are made parallel to the direction of the tissue fibers.

DISSECTION TECHNIQUE

• When incising tissue, a clean incision should be made through the skin with one stroke of evenly applied pressure on the scalpel.

• Sharp dissection should be used to cut through

remaining tissues.

• The surgeon must preserve the integrity of as many of the underlying nerves, blood vessels, and muscles as possible.

TISSUE HANDLING

• Keeping tissue trauma to a minimum promotes faster healing.

• Throughout the operative procedure, the surgeon must handle all tissues very gently and as little as possible.

• Retractors should be placed with care to avoid excessive pressure,

• since tension can cause serious complications: impaired blood and lymph flow,

• altering of the local physiological state of the wound, and predisposition to microbial colonization.

HEMOSTASIS

•Achieving complete hemostasis before wound closure willprevent formation of postoperative hematomas.

•Collections of blood (hematomas) or fluid (seromas) in the incision can prevent the direct apposition of tissue.

•These collections provide an ideal culture medium for microbialgrowth and can lead to serious infection.

•When clamping or ligating avoid excessive tissue damage.

•Mass ligation that involves large areas of tissue mayproduce necrosis.

MAINTAINING MOISTUREIN TISSUES

• During long procedures, periodically irrigate the wound with warm saline solution,

• or cover exposed surfaces with saline-moistened sponges to prevent tissues from drying out.

TreatmentTreatment

• Incisional: open surgical wound, Incisional: open surgical wound, antibiotics for cellulitis or sepsisantibiotics for cellulitis or sepsis

• Deep/Organ space: Source control, Deep/Organ space: Source control, antibiotics for sepsisantibiotics for sepsis

Care of the wound• Epithelialisation takes 48 hs.• Dressing can be removed 3-4 days after operation.• Wet dressing should be removed earlier and changed.• Symptoms and signs of infection should be looked for, which if

present compression, removal of few stitches and daily dressing with swab for C & S.

• Tensile strength of wound minimal during first 5 days, then rapid between 5th 20th day then slowly again (full strength takes 1-2 years).

• Good nutrition.

Management of drains

• To drain fluids accumulating after surgery, blood or pus.• Open or closed system.• Other types (Suction, sump, under water etc.)• Should be removed as long as no function.• Should come out throw separate incision to minimize risk of

wound infection.• Inspection of contents and its amount.• Soft drains e.g. Penrose should not be left more than 40 days

because they form a tract and acts as a plug.

• Drain use after elective laparoscopic cholecystectomy increases wound infection rates and delays hospital discharge. We could not find evidence to support the use of drain after laparoscopic cholecystectomy or open cholecystectomy.

• Many gastrointestinal operations can be performed safely without prophylactic drainage

• There is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications. Damage may be caused by mechanical pressure or suction and drains may even induce an anastomotic leak.

• Drains are not a substitute for good surgical technique

Thank You“The names of the patients whose lives we save can never be

known. Our contribution will be what did not happen to them”

Sources:•Pubmed National library of medicine•Loyola University Medical Center•Memon MA, Memon MI, Donohue JH; Abdominal drains: a brief historical review. Ir Med J. 2001 Jun;94(6):164-6