Download Treatment surgical site infection

Khaled Al-Omar
surgical site infections
 3rd most common nosocomial infection
14-16%
Most common nosocomial
infection among surgery
patients 38%
2/3 incisional
1/3 organ
Important Definitions
 Colonization
 Bacteria present in a wound with no signs or symptoms
of systemic inflammation
 Usually less than 105 cfu/mL
 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
Contd;
 Infection
 Systemic and local signs of inflammation
 Bacterial counts ≥ 105 cfu/mL
 Purulent versus nonpurulent
 Surgical wound infection is SSI
Criteria for defining SSIs
Further Classification
 Etiology
a) Primary
The wound is the primary site of infection
b)Secondary
Infection arises following a complication that is not
directly related to wound
Contd;
 Time
a) Early
Infection presents within 30 days of procedure
b) Intermediate
Occurs between one and three months
c) Late
Presents more than three months after surgery
Contd;
 Severity
a) Minor
Wound infection is described as minor when there is
discharge without cellulitis or deep tissue destruction
b) major
When there is pus discharge with tissue breakdown ,
Partial or total dehiscence of the deep fascial layers of
wound or if systemic illness is present.
Microbiology
Lactobacilli
Streptococci
Lactobacilli
Enterobacteriaceae
Aerobic
+
Anaerobic
Microbial
Populations
Pathogenesis
Bacterial dose
Virulence
Impaired
host resistance
Risk factors
Patient factors
 Diabetes
 Obesity
 Nicotine use
 Steroid use
 Malnutrition
 Hospital stay 
 Nares colonization with S. aureus
 Transfusion
 Diabetes
 Controversial
 Patients underwent CABG
@ Increasing levels of HbA1c and SSI rates
@ Increased glucose levels (>200 mg/dL)
 Nicotine use
 Delays primary wound healing
 Increase the risk of SSI
 Steroid use
 Controversial
 Malnutrition
 Theoretical arguments: increase the SSI risk
 Two randomized clinical trials: preoperative
“nutritional therapy” did not reduce incisional and
organ/space SSI risk.
 Prolonged preoperative hospital stay
 Preoperative nares colonization with S. aureus
 Mupirocin ointment:
Controversial
 Perioperative transfusion
 No scientific basis
Preop factors
 Preoperative antiseptic showering
 Preoperative hair removal
 Patient skin preparation in the operating room
 Preoperative hand/forearm antisepsis
 Antimicrobial prophylaxis
 Preoperative antiseptic showering
 Decreases skin microbial colony counts
 No evidance of benefit to reduce SSI rates
 Preoperative hair removal
 Shaving:
@ immediately before the operation: SSI rates 3.1%
@ shaving within 24 hours preoperatively: 7.1%
@ having performed >24 hours: SSI rate > 20%.
 Depilatories:
@ lower SSI risk than shaving or clipping
@ hypersensitivity reactions

Patient skin preparation in the operating room
 Most common used: Alcohol solutions
Chlorhexidine gluconate
Iodophors
 Preoperative hand/forearm antisepsis
Prophylactic antibiotics
 Class 1 = Clean
 Class 2 = Clean contaminated
 Class 3 = Contaminated
Prophylactic
antibiotics
indicated
 Class 4 = Dirty infected Therapeutic antibiotics
Wound
Classification
I
II-Biliary,GU,
Upper Digestive
II-Distal
Digestive
III/IV
Antibiotic
PCN Allergy
1st generation
Cephalosporin
1st generation
Cephalosporin
2nd generation
Cephalosporin
Vancomycin
Clindamycin
Vancomycin
Clindamycin
Aztreonam and
Clindamycin/Flagyl
Generally Therapeutic
Once the incision is made,
antibiotic delivery to the
wound is impaired.
Must give before incision!
ABX
Operative characteristics
 Operating room environment
 Surgical attire and drapes
 Asepsis and surgical technique

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

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 bloodborne 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.
Postoperative issues
 Incision care
  The type of postoperative incision care

@ closed primarily: the incision is usually covered

with a sterile dressing for 24 to 48 hours.

@ left open to be closed later: the incision is packed

with a sterile dressing.

@ left open to heal by second intention: packed
with

sterile moist gauze and covered with a sterile

dressing.
 Treatment surgical site infection

 Efflux of purulent material and pus
 Fascia is intact:
debridement
Irrigated with N/S and
packed to its base with saline-moistened gauze
 Fascia separated: drainage or reoperation
Most SSIs: healing by secondary intention

Discharge planning
 The intent of discharge planning:



maintain integrity of the healing incision,
educate the patient about the signs and symptoms
of infection,
advise the patient about whom to contact to report
any problems.