SURGICAL SITE

INFECTIONS

Presenter-Dr.Rahul A. Arya

Moderator -Dr.Amarchand Bajaj

Dr.M.C.Misra
WHY SSIs?
The facts surrounding surgical site infection are staggering

According to CDC report:

• 27 million surgical procedures performed annually in US, with a post-operative
infection rate of 2-3%. That translates to over 675,000 surgical site infections in the US
alone.
• Among surgical patients, SSIs are the most common hospital-acquired infections,
accounting for 38% of all such infections.
• SSIs are the third most common nosocomial (hospital-associated) infection and cause
approximately 20% of all hospital-acquired infections.
• SSI associated with 2-11 fold increase in risk of mortality.

Mangram A, et al, CDC guideline for prevention of surgical site infection. Infection Control & Hospital Epideminology, 2022;20(4):247-280
 WHY SSIs?
The facts surrounding surgical site infection are staggering

18.8 million annual procedures 27 million annual procedures

3–20% infection rate 2-3% infection rate

?225000 SSIs annually 675000 SSIs annually

Mangram A, et al, CDC guideline for prevention of surgical site infection. Infection Control & Hospital Epidemiology, 2020;20(4):247-280
Leaper D.J., et al, Surgical Site Infection – A European Perspective of Incidence & Economic Burden, Int. Wound J. 2004;1:247-273
History
ALEXANDER FLEMING
• The discovery of the antibiotic penicillin is attributed to Alexander
Fleming in 1928, but it was not isolated for clinical use until 1941 by
Florey and Chain.

• Fleming also discovered a substance called Lysozyme which is

bacteriolytic in tissue and secretions.

• Since then, there has been a proliferation of antibiotics with broad-

spectrum activity and antibiotics today remain the mainstay of
antimicrobial therapy.

• In 1945 he shared the Nobel prize for the discovery of the Penicillin's.
ALEXANDER FLEMING
DEFINITION &
CLASSIFICATION
Infection occurs within 30 days of procedure or within 1 year of implant placement
SUPERFICIAL INCISIONAL
DEEP INCISIONAL
ORGAN OR SPACE SSI
SURGICAL WOUNDS CLASSIFICATION
Surgical wounds
classification Definition
Clean Operations in which no inflammation is encountered and the respiratory,
(Class 1) alimentary or genitourinary tracts are not entered.
There is no break in aseptic operating theatre technique e.g.: hernioplasty,
thyroidectomy, surgeries of brain, joints, heart & transplant.

Clean- Operations in which the respiratory, alimentary or genitourinary tracts are

contaminated entered but without significant spillage. Eg: appendectomy, pancreatic &
(Class 2) biliary surgery(cholecystectomy).
Contaminated Operations where acute inflammation (without pus) is encountered, or where
(Class 3) there is visible contamination of the wound. Examples include gross spillage
from a hollow viscus during the operation or compound/open injuries
operated on within four hours, Penetrating trauma with gross intestinal spillage,
Appendicular perforation.
Dirty Operations in the presence of pus, where there is a previously perforated
(Class 4) hollow viscus, or compound/open injuries more than four hours. Eg: Abscess,
perforated viscous with peritonitis, faecal contamination.
INFECTION RATE (Before & After Prophylaxis)

Type of surgery Infection rate Infection rate before prophylaxis

Clean 1-2% Same

Clean contaminated <10% Gastric surgery up to 30%

Biliary Surgery up to 20%

Contaminated 15-20% Variable up to 60%

Dirty <40% Up to 60% or more

WOUND ASSESSMENT SCORE SYSTEM
PATHOGENS IN SSI
PATHOGENESIS
• The SSI Equation
Contamination X Virulence
Host competence
AIMS:
• Decrease contamination
• Decrease virulence
• Improve host competence
RISK FACTORS

Patient Factor Local Factor Microbial Factor

• Older age • Poor skin preparation • Prolonged

• Immunosuppression • Contamination of hospitalization
• Obesity instruments • Toxin secretion
• Diabetes mellitus • Inadequate antibiotic • Resistance to
• Chronic inflammatory prophylaxis clearance(capsule
process • Prolonged procedure formation)
• Malnutrition • Site and complexity of
• Peripheral vascular procedure
disease • Local tissue necrosis
• Smoking • Hypoxia
• Anemia
• Radiation
PRINCIPLES OF PREVENTION OF SSI

• Reduce or eliminate contamination

• Make the wound infertile for microbial growth

• Attack the contaminants, do not let them colonize

Surgical Care Infection Prevention (SCIP)
– An Evidence-Based Approach

• Timely and appropriate antimicrobial prophylaxis

• Glycemic control in cardiac and vascular surgery

• Appropriate hair removal

• Normothermia in general surgical patients

PRE OPERATIVE PHASE
Pre-op Shower:
• With soap (chlorhexidine soap)
• On the day of surgery of day before surgery( 8-12 hours prior)

Shaving:
• Limited to the area of surgery
• Day of surgery
• Disposable razor
• Depilation cream

– Electric clippers with single use Clipping

Ref:NICE Guideline on the treatment of surgical site infection, (National Institute for Health and Clinical Excellence, 2018-19.)
Comparison Between Rate Of Infection In Method Of Pre-operative
Shaving/Hair Removal

Technique No specific Immediate Within 24 More than 24

time before hours hours
No removal 0.6%
Razor 5.6% 3.1% 7.1% >20%
Clipper 1.8% 4%
BLOOD GLUCOSE CONTROL

• SSI reduced from 2.0% to 0.8% when sugar levels were

maintained <200mg%

• Tight glucose control is also beneficial in non diabetic

patients

*Funary AP et al 1999, #van der Berghe 2001

PRE OPERATIVE PHASE
Patient theatre wear:

• Give patients specific theatre wear that is appropriate for the

procedure and clinical setting, and that provides easy access
to the operative site and areas for placing devices, such as
intravenous cannulas.

• Take into account the patient's comfort and dignity.

PRE OPERATIVE PHASE
Theatre staff's dress

 Clean dress
 Cap & Mask
 Shoes
 Goggles

• Minimum movements in & out of the operative area

Ref: NICE Guideline on Prevention and treatment of surgical site infection, (National Institute for Health and Clinical Excellence, 2018-19.)
PRE OPERATIVE PHASE
• Mechanical bowel preparation:(controversial)

• Hand jewellery, artificial nails & polish

 The operating team should remove hand jewellery or artificial
nails or polish.
PRE OPERATIVE PHASE

Hand washing:
 Betadine scrub/Chlorhexidine
 3 - 5 minute ritual with soap and
water
 60-90 seconds with hand sanitizer
 HAND HYGIENE: WHEN?

• Before touching a patient

• After touching a patient

• Before aseptic techniques

• After touching the patient surrounding

• After removing gloves

Surgical - Antimicrobial Prophylaxis
• Important evidence based factor developed in the prevention of SSI

• Antibiotic prophylaxis is not aimed to make tissues sterile but to take

care of any inadvertent compromise taking place during conduction
of surgery.

• Select an Antibiotic with both Gram –ve & Gram +ve coverage

• Preferably 1st or 2nd generation Cephalosporins

• Given at the time of induction of Anesthesia - within 60 min of

starting surgery. Exceptions include Vancomycin and Levofloxacin
which requires within 120 min preprocedural incision.
 Surgical - Antimicrobial Prophylaxis

• Avoid using higher Antibiotics

• Single dose is sufficient in most of the cases.

• Re-dosing needed to keep antibiotic concentration within

therapeutic range for entire surgery.
• Indication:
Excessive blood loss >1.5L
Prolong surgery > 4 hours

• Continuation of prophylactic antibiotic post op doesn’t show any

benefit.
PREOPERATIVE PHASE

• Sterile Gown & Gloves

 Water resistant gowns
 Double glove technique
PREOPERATIVE PHASE
• Pre operative
scrubbing
• Surgical skin
preparation

 Iodine/
Chlorhexidine
 Allow it to
dry & avoid
spillage
to diathermy
pad.
INTRA OPERATIVE PHASE
Maintain Homeostasis

• Avoid Hypothermia
 Warm fluids for infusion and for lavage
 Warm blankets
 Warm mattress
 Monitor temperature every 30 min during surgery
• Avoid Hypoxia
 O2 Supplementation / monitor Spo2
• Avoid hypotension
 Infuse adequate fluids
 Surgical techniques prevent SSI

• Elective surgery
• Laparoscopic surgery
• Proper haemostasis
• Less trauma to the tissues

• Less use of diathermy

• Avoid drains
INTRAOPERATIVE PHASE

Reducing contamination:

• Sterile & Quiet environment

• To & fro movement to be kept at minimum.
• Ensure sterility of equipment's & theatre

• Laminar airflow/Filters
LAMINAR AIR FLOW
 VENTILATION

• Temperature: 21+/- 3 C

• Relative humidity: 30-60%

• Air movement: >20 total per hour

• Air changes: >4 outdoor air per hour

POST OPERATIVE MANAGMENT

• Change of dressings:
 Use an aseptic non-touch technique for changing or removing surgical
wound dressings.

• Postoperative cleansing:
 Use sterile saline & betadine for wound cleansing up to 48 hours after
surgery.
 Advise patients that they may shower safely 48 hours after surgery.
 SSI at SBISR
• October 2021- September 2022:

o Total number of case: 2,661 cases

o Total number of SSI: 22 cases

o Percentage of SSI at SBISR: 0.826%

 Benefits of Laparoscopy in
prevention of SSI
• Small incisions
• Reduced blood loss
• Reduced operative time
• Reduced operative stress

• Reduced hypothermia
• Reduced hospital stay
INNOVATIVE STRATEGIES TO REDUCE INFECTION

WITHIN THE NOSOCOMIAL ENVIRONMENT

Antibacterial Devices – FDA approved
Antiseptic cloth – 2% CHG impregnated
Urologic devices – Foley catheters – hydrogel/silver
– Ureteral stents – triclosan eluting
– Implantable prostheses – antibiotic

Central venous catheters – CHG-impregnated ring (cuff)

– Silver alone
– Silver sulfadiazine
– SS/CHG

Peritoneal catheters – Silver coated

Vascular catheters – Silver/antibiotics coated
Orthopaedic devices – External fixation pins - silver
– Antibiotic impregnated PMM
Surgical sutures – Braided, monofilament, PDS - triclosan
TAKE HOME MESSAGE
• Good surgical technique & operative environment
• Control of Hyperglycemia
• Proper Hair removal technique
• Avoiding Hypothermia
• Prophylactic Antibiotics
• Proper selection of suture material
• Reduced Hospital stay – Day Care Surgery
• Treating remote site infection
• Proper usage of Cap / Mask / Gloves/ Gowns
• Pre op bathing – Antiseptic shower
Thank You