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 Nicotine :
effects & delays 10
reduced oxygen wound
carrying healing
capacity

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
Recommendations-
Preoperative
Preparation of the patient
Preoperative antiseptic showering
Preoperative hair removal
Antibiotic prophylaxis
Hand/forearm antisepsis for surgical team members
Recommendations-
Preoperative
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)
Recommendations-
Preoperative
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)
Recommendations-
Preoperative
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%.
Recommendations-
Preoperative 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)
Recommendations-
Preoperative
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.
Recommendations-
Antibiotic 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)
Recommendations-
Antibiotic 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
Recommendations-
Intraoperative
Operating room environment
Surgical attire and drapes
Asepsis and surgical technique
Recommendations-
Antiseptic 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)
Recommendations-
Intraoperative
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
Recommendations-
Postoperative
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)
Recommendations-
Information 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