Surgical Site Infection

 Third most reported nosocomial infections

 16% of all reported nosocomial infections
 Most common surgical patient nosocomial
infection (38%)
 2/3 involved surgical incision, 1/3 deep
structures accessed by incision
 Deaths in patients with nosocomial infections
—77% related to infection.
Definitions
Infection here may cause:

Delayed healing

Hernia
Possible evisceration

Abscess
Fistula
Other procedures needed
Superficial SSI

)PURULENT DRAINAGE from superficial incision•

or
Positive culture from a closed surgical site obtained aseptically•
or
,One of : Pain or tenderness, localized swelling, redness, heat•
And wound dehiscence, abscess or wound reopening
 Deep Incisional SSI

Infection involves deep soft tissues )e.g., fascial and muscle•

(layers
:and at least one of the following
Purulent drainage from deep incision but not from. 1•
organ/space
Deep incision dehiscence or opened by surgeon when. 2•
patient has at least one of: fever )>38ºC(, localized pain, or
tenderness, unless site is culture-negative
Abscess or other evidence of infection of deep incision on. 3•
direct examination, reoperation, histopathologic or radiologic
exam
Organ /Space SSI

(Infection involves organs or spaces )other than incision•

opened or manipulated during an operation
:and at least one of the following
Purulent drainage from a drain that is placed through a. 1•
stab wound into the organ/space
Organisms isolated from an aseptically obtained culture of. 2•
fluid or tissue in the organ/space
An abscess or other evidence of infection organ/space on. 3•
direct examination, reoperation, histopathologic or radiologic
examination
 Microbiology of SSIs
1986-1989 1990-1996
)N=16,727( )N=17,671(

PseudomonasStaphylococcus PseudomonasStaphylococcus
aeruginosa aureus aeruginosa aureus
8% 17% 8% 20%

Enterococcus Enterococcus
spp. spp.
8% 12%

Escherichia Coagulase neg. Escherichia Coagulase neg.

coli staphylococci coli staphylococci
10% 12% 8% 14%
The Usual Presentation of the Data
CABG Colorectal THR TKR

No of procedures 383,000 250,000 293,000 324,000

No. of SSIs 14,975 15,075 4,109 3,726

% SSIs 3.9% 6% 1.4% 1.15%

No. Deaths 11,107 11,500 3,809 648

Cost $Millions $83.5 $127 $196 $63

Source: NNIS data from Barnard BM 4/1/02 Infection Control Today

Risk factors for SSI
 Diabetes

 Nicotine

 Steroids

 Malnutrition

 Length of preoperative hospitalization

 Nares colonization Staph Aureus

 Perioperative transfusion
Patient Factors
 Local:  Systemic:
 High bacterial load
 Wound hematoma
 Necrotic tissue
 Foreign body
 Obesity
 Advanced age
 Shock
 Diabetes
 Malnutrition
 Alcoholism
 Steroids
 Chemotherapy
 Immuno-compromise
Preop
 Scrub
 10 or 2 min ? With what?
 Skin prep
 Iodophors, chlorahexadine, or ETOH
 Hair removal
 Night before? NO (5% vs .6%)
 Antiseptic showering
 Reduce skin flora only
Elective Surgical Procedures
Hair Removal
Hair Removal Method Infection Rate
PM Razor 8.8% - 5.2
AM Razor 10% - 6.4
PM Clipper 7.5% - 4
AM Clipper 3.2% - 1.8

Alexander JW, et al. Arch Surg

1983; 118:347-352
Pre-operative Antiseptic
Showers/Baths
Most studies examine effects on skin colony counts
antiseptic showering decreases colony counts

Few studies examine effect on SSI rates

No Shower Shower
Cruse, 1973 2.3% 1.3%

Ayliffe, 1983 4.9% 5.4%

Rooter, 1988 2.4% 2.6%

What are the initiatives regarding
(?Surgical Site Infection )SSI

 Antibioticchoice, dose, delivery, duration

 Surgical site preparation

 Perioperative control of glucose

 Maintenance of normothermia

 Supplemental perioperative oxygen

Elective Surgical Procedures
Prevention of Hyperglycemia
 80 mg/dl> BG<110mg/dl decreased:
 ICU mortality (8%-4.6%)
 Sepsis (blood stream infection by 46%)
 ARF requiring HD (41%)
 RBC transfusion (50%)
 Polyneuropathy (44%)
 Independent variable with conventional care

Volume 345:1359-1367 November 8, 2001 Number 19

Intensive Insulin Therapy in Critically Ill Patients
Greet Van den Berghe, M.D., Ph.D., Pieter Wouters, M.Sc., Frank Weekers, M.D.,
Charles Verwaest, M.D., Frans Bruyninckx, M.D., Miet Schetz, M.D., Ph.D.,
Dirk Vlasselaers, M.D., Patrick Ferdinande, M.D., Ph.D., Peter Lauwers, M.D.,
and Roger Bouillon, M.D., Ph.D.
 Glucose control (200 mg/dl)
decreases infection rate

SSIs and Glucose Levels CTS pts

Deep Infection Rate, % 8
6.7%
7
6
P=0.002
5
4
2.5%
3 1.3% 1.6%
2
1
0
100–150 150–200 200–250 250–300
Day 1 Blood Glucose )mg/dL(

Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations,
page 360. Reprinted from The Annals of Thoracic Surgeons, Vol. 63.
 Elective Surgical Procedures
Perioperative Normothermia

Warm Patient Strategies:

 200 CRS patients
•Start with warm room
•Use
 Control: Routine intraoperative Bair Hugger
thermal care
(mean temperature 34.7°C) •Cool room for procedure
•Use 40o irrigation
 Treatment: Active warming
•Warm room on closing
(mean temperature 36.6°C)
GOAL : >36oC (98.6oF)
 Incidence of SSI
 Control 19% (18/96)
 Treatment 6% (6/104); P=0.009
cold patients
had 3x infection
rate
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
Elective Surgical Procedures
Supplemental Oxygen
 500 CRS patients
 80% or 30% inspired oxygen during operation and
for 2 hours post surgery
 All patients received prophylactic antibiotics
Oxygen Strategy:
 Results
•Supplemental O2 for 2hrs in RR
 Arterial and subcutaneous PO higher in
2

80% oxygen group

low O
 Lower incidence of SSIs with higher2 supplemental
oxygen (5.2% vs 11.2%; P=0.01)2x
infection
rate

Greif et al. N Engl J Med. 2000;342:161–167.

Chlorhexadine 4%/Alcohol Prep
March 19, 2003 – February 29, 2004
Total Knee/Total Joint Recommendations
Recommendation Number %
Cases Reviewed 258

Chlorhexadine 4%/alcohol prep 235 91.1%

Betadine Scrub + alcohol prep 16 6.8%

Surgical Attire
Scrub suits 

Cap/hoods 

Shoe covers 

Masks 

Gloves 

Gowns 
Surgical Technique

Removing devitalized tissue

Maintaining effective hemostasis
Gently handling tissues
Eradicating dead space
Avoiding inadvertent entries into a viscus
Using drains and suture material
appropriately
Parameters for Operating Room
*Ventilation
Temperature: 68o-73oF, depending on
normal ambient temp
Relative humidity : 30%-60%
Air movement: from “clean to less clean”
areas
Air changes : >15 total per hour
outdoor air per hour 3>
*American Institute of Architects, 1996
Role of Laminar Air Flow
)Ultraclean Air( in Preventing SSI
Most studies involve only orthopedic operations
Lidwell et al: 8,000 total hip and knee replacements
ultraclean air: SSI rate ↓3.4%
to 1.6% antimicrobial prophylaxis (AP): SSI rate
↓3.4% to 0.8% ultraclean air + AP: SSI rate
↓3.4% to 0.7%
History of Anti-infective Drugs for Surgical Prophylaxis in Colorectal
(Surgery )CRS

1961: Animal studies by Burke demonstrated the importance of timing in

preventing dermal or incisional infection.1
1969: Landmark study by Polk and Lopez-Mayor demonstrated a
significant reduction of wound and intraabdominal sepsis among
patients treated with antimicrobial prophylaxis.2
1970s: Key Veterans’ Affairs trials showed benefit of antibiotic
prophylaxis over placebo in elective CRS
 9% wound infection rate in antibiotic-treated patients vs
35% in placebo group3
 Infection in 0 of 69 patients receiving neomycin-erythromycin
base vs 3 of 16 patients receiving mechanical preparation only4
1981: Baum and colleagues recommended elimination of “no-treatment”
control groups in trials of antibiotic prophylaxis in colon surgery5
1998: Song and Glenny review of 147 trials between 1984 and 1995.6

1. Burke JF. Surgery. 1961;50:161–167. 4. Nichols RL, et al. Ann Surg. 1973;178:453–459.
2. Polk HC Jr, et al. Surgery. 1969;66:97–103. 5. Baum ML, et al. N Engl J Med. 1981;305:795–799.
3. Clarke JS, et al. Ann Surg. 1977;186:251–258. 6. Song F, et al. Br J Surg. 1998;85:1232–1241.
Antimicrobrial prophylaxis
 Clean contaminated procedures

 Clean
 Vascular cases, prosthesis, immune suppression,
mesh.
 Timing

 Selection
Percent of Abx Given Within 1 Hour of Incision
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Overall Rate Hip and Knee Hysterectomy Colon Surgery
Arthroplasty

Surgery Type Successes# Cases# Percent

Overall Rate 912 921 99%

Hip and Knee Arthroplasty 652 655 99.5%
(2nd Qtr 2003 – 2nd Qtr 2005)

Hysterectomy 254 259 98%

(3rd Qtr 2004 – 2nd Qtr 2005)

Colon Surgery 6 7 86%

(May, 2005 – July, 2005)
Percent of Prophylactic Abx Discontinued
Within 24 Hours After Surgery End Time
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Overall Rate Hip and Knee Hysterectomy Colon Surgery
Arthroplasty

Surgery Type # Cases# Percent

Successes

Overall Rate 829 921 90%

Hip and Knee Arthroplasty 582 655 89%
(2nd Qtr 2003 – 2nd Qtr 2005)

Hysterectomy 243 259 94%

(3rd Qtr 2004 – 2nd Qtr 2005)
(Class I )clean
 Atraumatic wound w/o inflammation. No
respiratory, GU,GI,or biliary tract entered

 Hernia repair

 1.5% infection rate

(Class II)clean/contaminated
 Controlled entrance into respiratory, GU,GI,or
biliary tracts

 Cholecytectomy, elective bowel resection

 7.5% infection rate

(Class III)contaminated
 Traumaticwounds, major breaks in sterile
techniques, gross spillage of GI contents,
Acute non-purulent inflammation

 Appendectomy

 15% infection rate

Wound Classification
(Class IV )dirty
 Oldtrauma wounds; devitalized tissue;
existing clinical infection, perforated viscera.

 Hartmann’s for diverticular perforation

 40% infection
Antibiotics
 Prophylactic

 Therapeutic
Infections
 Two main types

 Community-Acquired

-- Hospital-Acquired
Community-Acquired
 Skin/soft tissue
 Cellulitis: Group A strep
 Abcess/furuncle: Staph aureus
 Necrotizing: Mixed
 Hiradenitis suppurativa: Staph aureus
 Lymphangitis: Staph aureus
Cellulitis
Necrotizing Soft Tissue
Infection
 Mortality rate as high as 40% (17%)
 Impaired immune system

 Compromised tissue blood supply

 Microorganisms (Polymicrobial)

 “skin poppin’” or “muscling”

 1/3 dibetics

 90% comorbid conditions

Necrotizing
Necrotizing Soft Tissue
Infection
 Debridement/Resuscitation

 Debridement

 Debridement

 Antibiotics

 Nutrition
 1.5 to 2 times basal requirements
 Treatment delays are predictive of adverse
outcome
Hydradenitis suppurativa
 axilla,groin, perineum, any skin fold
 Single abscess treated by I&D

 Doxycycline 100mg BID

 Excision with STSG (15%)

 Infection of apocrine sweat glands

Hiradenitis
Community-Acquired
 Breast Abcess
 Staphylococcal infection
 Usually post-partum
 Treatment
-- MRSA is uncommon
Breast Abscess
Infected Vascular Graft
 Inguinalincision is independent risk factor
 Length of case and blood loss

 0.5% to 5%

 Prosthetic HD grafts 10%-20%

 S. Aureus
 Extracellular glycocalyx
 Negative culture
 Summary

 Optimal antibiotic choice, dose, delivery,

duration
 Optimal surgical site preparation

 Perioperative control of glucose

 Maintenance of normothermia

 Supplemental perioperative oxygen