A paradox :

Surgical Site Infection (SSI)

Prevention without Killing
Bacteria
Oleh : Dr Hadiyana Suryana, Sp.B. FINACS
 Outline :
I. Important issues in the approach to surgical site infection
prevention
II. Epidemiology and burden worldwide
III. General Peri-Operative Risk factor of SSI
IV. Specific risk factors of SSI : Surgical Classification
V. Definition of Surgical Site Infection (SSI)
VI. Impact of SSI
VII. Classification of dressings suitable for use on primarily closed
incisions
VIII. The variety of topical dressings to prevent & manage SSI wounds
IX. What happens if bacteria killed?
X. New Concept : No Risk of Antimicrobial Resistance & release
Endotoxin

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 Important issues in the approach to
surgical site infection prevention
 Health care-associated infections (HAIs) are acquired by patients when receiving care and are the most
frequent adverse event affecting patient safety worldwide.
 Common HAIs include urine, chest, blood and wound infections. HAIs are caused mainly by
microorganisms resistant to commonly-used antimicrobials, which can be multidrug-resistant. It is
estimated that hundreds of millions of patients are affected by HAIs each year, leading to significant
mortality and financial losses for health systems. At present, no country is free from the burden of
disease caused by HAIs and antimicrobial resistance (AMR).
 Recent work by the World Health Organization (WHO) Clean Care is Safer Care programme
(http://www.who.int/gpsc/en) shows that surgical site infection (SSI) is the most surveyed and frequent type of HAI in LMICs (low-
and middle-income Countries) and affects up to one third of patients who have undergone a surgical
procedure.
 The European Centre for DiseasePrevention and Control (ECDC) reported data on SSI surveillance for
2010-2011. The highest cumulative incidence was for colon surgery with 9.5% episodes per 100
operations, followed by 3.5%for coronary artery bypass graft, 2.9% for caesarean section, 1.4% for
cholecystectomy, 1.0% for hip prosthesis, 0.8% for laminectomy and 0.75% for knee prosthesis (3).

WHO. 2017.Global Guidelines for the Prevention of Surgical Site Infection

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 Important issues in the approach to
surgical site infection prevention
Infection prophylaxis increasingly becomes a concern for many doctors,
nurses and hospitals.
Surgical Site Infection (SSI) is painful, costly and detrimental for reputation.

Figure: Cause of health care-associated infections

C*enter for Disease Control and Prevention (CDC) estimate, 2011

Citatiom from
http://pharmacypracticenews.com/ViewArticle.aspx?d=Technology&d_id=52&i=September%2B2010&i_id=663&a_id=15831
(23.03.2013)
4 13 July, 2020
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 Epidemiology and burden
worldwide
 In 2010, an estimated 16 million surgical procedures were
performed in acute care hospitals in the USA (13). In a recent
report on the rates of national and state HAIs based on data from
2014, 3654 hospitals reported 20 916 SSI among 2 417 933 surgical
procedures performed in that year. AMR patterns of HAI in the USA
have been described and compared to a previous report. Among
the 1029 facilities that reported one or more SSI, Staphylococcus
aureus was the most commonly reported pathogen overall (30.4%),
followed by coagulase-negative staphylococci (11.7%), Escherichia
coli (9.4%) and Enterococcus faecalis (5.9%).
 The European point prevalence survey of HAIs and antimicrobial
use conducted in 2011-2012 showed that SSIs are the second most
frequent HAI in hospitals.
 The WHO report on the global burden of endemic HAI provided SSI
data from LMICs. The pooled SSI incidence was 11.8 per 100
surgical patients undergoing surgical procedures (95% CI: 8.6 –
16.0) and 5.6 per 100 surgical procedures (95% CI: 2.9 –10.5). SSI
was the most frequent HAI reported hospital-wide in LMICs and the
level of risk was significantly higher than in developed countries.
WHO. 2017.Global Guidelines for the Prevention of Surgical Site Infection

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 ▪ The length of the surgical procedure
▪ Blood transfusion
General ▪ Obesity

Peri-Operative ▪ Tobacco use

▪ Immunosuppressive medication, including non-steroidal
Risk factor of SSI anti-inflammatory drugs (NSAIDS)

▪ Length of pre-operative stay

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Specific risk factors of SSI :
Surgical Classification

Classification of surgical procedures by risk of infection (Mangram et al., 1999)

What is a Surgical Site Infection (SSI)?

Infections related to the operative procedure that occur at or near the surgical
incision (incisional or organ/space) within 30 days of an operative procedure or
90 days if prosthetic medical device is implanted
Update on surgical site infections: The new CDC guideline. JAAPA, 2018 Apr;31(4):52-54

Surgical site infection refers to an infection that occurs after surgery in the part of
the body where the surgery took place. Surgical site infections can sometimes be
superficial infections involving the skin only. Other surgical site infections are more
serious and can involve tissues under the skin, organs, or implanted material.
(Source: United States Centers for Disease Control and Prevention.https://www.cdc.gov/HAI/ssi/ssi.html, accessed 11 July 2016.).
 Impact of SSI

Globalsurg Collaborative, Lancet Inf Dis 2018; 18: 516-25

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 WHO. Global Guidelines for the Prevention of Surgical Site Infection.2017

Classification of dressings
suitable for use on primarily
closed incisions

GDG (Guidelines Development Group)

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 The variety of topical dressings to prevent & manage SSI wounds
Different modes of action may have a different impact of wound healing

Antibiotic agent Killing bacteria

▪ Inhibits DNA replication ▪ Disrupts cell wall and plasma membrane

Silver dressing ▪ Affects membrane of organelles ▪ Inactivates enzymes1

PHMB Disrupts cell walls and cell membranes 2

Iodine Disruption of proteins and cell membranes 3

Honey High osmolarity affects integrity of cell wall 4

DACC Hydrophobic binding. No disruption of cell walls 5

WHO. 2017.Global Guidelines for the Prevention of Surgical Site Infection

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 What happens if bacteria killed?

Antimicrobial agent mostly work by killing bacteria and destroy the cell wall.

The effect :
1. Resintance development (Antimicrobial
Resistance/AMR)
2. The release of endotoxins, which may
prolong inflammation

Butcher, M. DACC antimicrobial technology: a new paradigm in bioburden management. MA Healthcare, 2011.

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 What happens if bacteria killed?
1. RESISTANCE

The lower HDI tend to higher antibiotic resistance

Globalsurg Collaborative, Lancet Inf Dis 2018; 18: 516-25

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 What happens if bacteria killed?
2.WHAT
RELEASE OF ENDOTOXIN
ANTIBIOTICS DID ?
The destruction of bacteria
potentially increases the release
of endotoxins, especially from
the cell membrane of gram-
negative bacteria, as
demonstrated in in vitro studies
involving antibiotic agents.

Metzger Z, Nitzan D, Pitaru S, Brosh T, Teicher S. The effect of bacterial endotoxin on the early tensile strength of healing surgical wounds. J Endod 2002;28:30–3.

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 What happens if bacteria killed?
2. RELEASE OF ENDOTOXIN
The effect of ENDOTOXIN RELEASE :
• Endotoxin release may trigger a
number of local and systemic
reactions.
• It only takes 100 ng of purified
endotoxins to prompt fever in human
beings; doses of several milligrams
can lead to death.
• With regard to wound care,
contamination caused by endotoxins
released from bacteria can delay the
healing process .

Metzger Z, Nitzan D, Pitaru S, Brosh T, Teicher S. The effect of bacterial endotoxin on the early tensile strength of healing surgical wounds. J Endod 2002;28:30–3.

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 New Concept : No Risk of
Antimicrobial Resistance &
release Endotoxin
 When two water-repellent (hydrophobic)
surfaces come into close proximity, they bind
with one another by hydrophobic interaction
and expel water molecules (Fig 1).
 DACC (dialkylcarbamoyl chloride) is a highly
hydrophobic substance that, coupled with the
hydrophobic nature of bacterial cell walls,
mediates the irreversible binding of
microorganisms to DACC-coated dressings.
 When applied directly to the wound bed, this
results in binding of bacteria and fungi to the
dressing surface. The bound microorganisms are
subsequently removed at dressing change
resulting in a decrease in wound bioburden.
Chadwick, paul. Bacterial-binding dressings in the management of wound healing and infection
prevention: a narrative review. JOURNAL OF WOUND CARE VOL 28, NO 6, JUNE 2019

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 Benefit of Hydrophobic Interaction
Rather than killing the bound microorganisms (as would happen with antibiotics or
antiseptics) have some benefit :

No development of bacterial or fungal resistances has been described 5

No healing delays due to bacterial, cell debris or endotoxin release 3

No contraindications known 5

Suitable for prolonged treatment durations

Low risk of allergies 5

3 Cutting, McGuire, “Safe bioburden management: a clinical review of DACC technology”, 2015 Chadwick, paul. Bacterial-binding dressings in the management of wound healing and infection prevention: a narrative review.
5 Bateman, “Evidence is building to support using DACC-coated antimicrobial wound contact JOURNAL OF WOUND CARE VOL 28, NO 6, JUNE 2019
layer with NPWT”, Wounds UK, 2015
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 Summary

 To prevent Surgical Site Infection (SSI), perioperative procedure must

be prepared thoroughly.
 Using appropriate dressing is one of the consideration to manage SSI.
 Recommendation dressing for prevent SSI should not trigger side
effect such as antimicrobial resistance and release endotoxin which
may delayed wound healing

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