NOSOCOMIAL INFECTION

(HOSPITAL ACQUIRED
CONDITIONS)
AND SURGICAL SITE INFECTION

Jocliedian G L
Deny Budiman
Achmad Prihadianto
Hendrikus MB Bolly

What
What are
are Hospital
Hospital Acquired
Acquired Infections
Infections
(HAIs)
(HAIs)

Blood
Blood Stream
Stream Infections
Infections
Ventilator
Ventilator Associated
Associated Pneumonia
Pneumonia (VAP)
(VAP)
Surgical
Surgical Site
Site Infections
Infections (SSI)
(SSI)
Urinary
Urinary Catheter
Catheter Associated
Associated Infection
Infection
(CAUTI)
(CAUTI)
Multi-drug
Multi-drug Resistant
Resistant Organism
Organism (MRO)
(MRO)

Blood
Blood Stream
Stream Infections
Infections
(BSI)
(BSI)

Blood Stream Infections occur after the

insertion of an IV catheter either
peripherally or centrally within 48 hours
of insertion up to 48 hours after removal.
A BSI requires 2 positive blood cultures,
with pathogens not related to an other
infection.
PSMH as adopted the Central Line
Insertion Bundle to help prevent Central
Line Blood Stream Infections.

Ventilator
Ventilator Associated
Associated
Pneumonia
Pneumonia (VAP)
(VAP)

Ventilator Associated Pneumonia is

defined as a lung infection occurring after
a patient is placed on the ventilator. The
diagnosis is confirmed by analysis of the
infection by the Infection Control
Department

Surgical
Surgical Site
Site Infections
Infections
(SSI)
(SSI)

Surgical site infections are defined as

infections that occur within 30 days of
surgery, unless an implant is inserted
during the procedure then the time
increases to 3 months.
All reported SSIs are analyzed for
preventability and reports are provided to
the Infection Control Committee,
Department of Surgery, Clinical
Operations, Quality Board, CMS Core
measures, and CDC.

Catheter
Catheter Associated
Associated Urinary
Urinary
Tract
Tract Infections
Infections (CAUTI)
(CAUTI)

Urinary Catheter Associated Infections

are defined as an infection occurring 48
hours after insertion of a urinary
catheter, signs and symptoms of
infection (fever, pain, frequency, urgency,
increased white count, etc.) and a
positive urine culture of 100,000CFU/ml
with no more than 2 species of bacteria.

Multidrug
Multidrug Resistant
Resistant Organism
Organism
(MRO)
(MRO)

Multidrug resistant organisms of concern

at PSMH are Methicillin Resistant
Staphylococcus Aureus (MRSA),
Vancomycin Resistant Entercoccus (VRE)
and Clostridium Difficile (C. Dif)
MROs are bacteria that have become
resistant to many of the antibiotics used
to treat infections caused by them.

SSI Definition
A surgical site infection is an infection that occurs
after surgery in the part of the body where the
surgery took place. Most patients who have
surgery do not develop an infection. However,
infections develop in about 1 to 3 out of every
100 patients who have surgery.
Some of the common symptoms of a surgical site
infection are:
Redness and pain around the area where you had
surgery
Drainage of cloudy fluid from your surgical wound
Fever

Types of SSI
Superficial Incisional SSI
Infection occurs within 30
days after the operation
and involves only skin or
subcutaneous tissue
of the incision
Skin

Superficial
incisional
SSI

Subcutaneou
s tissue

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Deep Incisional SSI

Infection occurs within 30 days after the operation if
no implant is left in place or within 1 year if implant is
in place and the infection appears to be related to the
operation and the infection involves the deep soft
tissue (e.g., fascia and muscle layers)

Superficial
incisional SSI

Deep soft tissue

(fascia &
muscle)
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Deep
incisional SSI

Organ/Space SSI
Infection occurs within 30 days after
the operation if no implant is left in
place or within 1 year if implant is in
place and the infection appears to
be related to the operation and the
infection involves any part of the
anatomy, other than the incision,
which was opened or manipulated
during the operation

Superficial
incisional
SSI

Deep
incisional SSI

Organ/
space
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Organ/spac
e SSI

SSI Risk Factors

Operation Factors

Duration of surgical
scrub
Maintain body temp
Skin antisepsis
Preoperative shaving
Duration of operation
Antimicrobial
prophylaxis
Operating room
ventilation
Inadequate sterilization
of instruments

Foreign material at
surgical site
Surgical drains
Surgical technique
Poor hemostasis
Failure to obliterate
dead space
Tissue trauma

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

SSI Risk Factors

Patient Characteristics

Age
Diabetes
HbA1C and SSI
Glucose > 200 mg/dL
postoperative period
(<48 hours)

Nicotine use: delays

primary wound healing
Steroid use:
controversial
Malnutrition: no
epidemiological
association
Obesity: 20% over ideal
body weight

Prolonged preoperative stay:

surrogate of the severity
of illness and comorbid
conditions
Preoperative nares colonization
with Staphylococcus aureus:
significant association
Perioperative transfusion:
controversial
Coexistent infections at a remote
body site
Altered immune response

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

SSI Pathogens

Staphylococcus aureus - 30.0%

Coagulase-negative staphylococci - 13.7%
Enterococcus spp - 11.2%
Escherichia coli - 9.6%
Pseudomonas aeruginosa - 5.6%
Enterobacter spp - 4.2%
Klebsiella pneumonia - 3.0%
Candida spp - 2.0%
Klebsiella oxytoca - 0.7%
Acinetobacter baumannii - 0.6%
Hidron AI, et.al., Infect Control Hosp Epidemiol 2008;29:996-1011 ;ERRATUM

Surgical Site Infection Prevention Bundle

Components

1. Prophylactic antibiotic given within one

hour prior to surgical incision
2. Prophylactic antibiotic selection for surgical
patients
3. Prophylactic antibiotics discontinued
within 24 hours after surgery end time
(48 hours for cardiac surgery)
4. Cardiac surgery patients with controlled 6
A.M. postoperative serum blood glucose

Surgical Site Infection Prevention Bundle

Components

5. Surgery patients with appropriate hair

removal
6. Surgery Patients with Perioperative

Temperature Management - maintaining

normothermia
7. Urinary Catheter Removal on
Postoperative Day 1 or 2 with day of
surgery being day zero.

Surgical Site Infection Prevention Bundle

Components

1. Prophylactic antibiotic given within one

hour prior to surgical incision
-The goal of prophylaxis with antibiotics is to
establish bactericidal tissue and serum levels at the
time of incision.
Rationale: reduce the microbial burden of
intraoperative contamination to a level that cannot
overwhelm host defenses.*

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle

Components
2. Prophylactic antibiotic selection for surgical
patients
Surgical patients who received prophylactic antibiotics
consistent with current guidelines (specific to each type
of surgical procedure) have fewer surgical site infections
Rationale: Use an AMP (surgical antimicrobial
prophylaxis) for all operations or classes of operations
in which its use has been shown to reduce SSI rates
based on evidence from clinical trials*

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle

Components

3.Prophylactic antibiotics discontinued

within 24 hours after surgery end time
Rationale: Short duration antibiotics are as
effective in preventing infection as long
duration antibiotics
Long duration antibiotics are more likely to
cause development of drug resistant bacteria

Surgical Site Infection Prevention Bundle

Components

4. Cardiac surgery patients with controlled

postoperative blood glucose
Rationale: Hyperglycemia has been
associated with increased in-hospital
morbidity and mortality for multiple medical
and surgical conditions.
-Risk of infection is significantly higher for
patients undergoing CABG if blood glucoses
are elevated.
-Deep wound infections in diabetic patients
undergoing cardiac surgery is reduced by
controlling blood glucose levels < 200 mg/dL

Surgical Site Infection Prevention Bundle

Components

5. Surgery patients with appropriate hair removal

Hair removal, if indicated should be accomplished
with clippers rather than razors or depilatories.
Rationale: Razor shaving has been associated with
increased SSIs attributed to microscopic cuts in the
skin that serve as foci for bacterial multiplication*

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle

Components
6. Surgery Patients with Perioperative Temperature
Management - Maintaining normothermia
Surgery patients for whom either active warming was
used intraoperatively for the purpose of maintaining
normothermia or who had at least one body
temperature 96.8oF/36oC recorded within the 30
minutes prior to or the 15 minutes immediately after
anesthesia end time.

Rationale: Hypothermia (<36oC) increases the

risk for surgical site infection

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Surgical Site Infection Prevention Bundle

Components

7. Urinary Catheter Removal on

Postoperative Day 1 or 2 with day of
surgery being day zero.
Rationale: Removing the indwelling urinary
catheter decreases risk of urinary tract
infection and associated complication of
bacteremia that could lead to increased
length of stay, more frequent readmissions
and increased morbidity and mortality

*CDC Guideline for Prevention of Surgical Site Infections, 1999

Risk Stratification

ASA (American Society of Anesthesiology)

score given by anesthesia to reflect the
patients health at the time of surgery.
Wound class from clean to dirty (class
1-4)
Length of time between making and
closing incision

Minimize the Risk

Appropriate site prep

Appropriate hand scrub
Adequate fingernail care
Healthy healthcare provider

Opportunity to Prevent SSI

An estimated 40%60% of SSIs are

preventable
Overuse, underuse, improper timing,
and misuse of antibiotics occurs in
25%50% of operations

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

Principles of Antibiotic
Prophylaxis
Preop administration, serum levels adequate
throughout procedure with a drug active
against expected microorganisms.
High Serum Levels
1. Preop timing
2. IV route
3. Highest dose
of drug

During
Procedure
1. Long half-life
2. Long procedure
redose
3. Large blood
lossredose

Duration
1. None after
wound closed
2. 24 hours
maximum

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

SSI Prevention Strategies: CORE

Administer antimicrobial prophylaxis in
accordance with evidence based standards
and guidelines
Administer within 1-hour prior to incision
(2hr for vancomycin and fluoroquinolones)
Select appropriate agents on basis of:
-Surgical procedure
-Most common SSI pathogens for the procedure
-Published recommendations
Discontinue antibiotics within 24hrs after surgery
(48 hrs for cardiac)

Identify and treat remote infections when possible

Before elective operation
Postpone operation until infection resolved
Hair removal
Do not remove hair at the operative site unless it
will interfere with the operation
Do not use razors
If necessary, remove by clipping or by use of a
depilatory agent

Skin Prep
Use appropriate antiseptic agent and technique for skin
preparation
Operating Room (OR) Traffic
Keep OR doors closed during surgery except as needed
for passage of equipment, personnel, and the patient
Colorectal surgery patients
Mechanically prepare the colon (Enemas, cathartic
agents)
Administer non-absorbable oral antimicrobial agents in
divided doses on the day before the operation

Maintain immediate postoperative normothermia

Surgical Wound Dressing
Protect primary closure incisions with sterile
dressing for 24-48 hours post-op
Control blood glucose level during the immediate
post-operative period - cardiac
Measure blood glucose level at 6 am on post-op
day 1 and 2 (procedure day = day 0)
Maintain post-op blood glucose level at
<200mg/dL

Nasal screen for Staphylococcus aureus on patients

undergoing
elective cardiac surgery, orthopedic, neurosurgery
procedures with implants
decolonize carriers with mupirocin prior to surgery
Screen preoperative blood glucose levels and
maintain tight glucose control post-op day 1 and 2
in patients undergoing select elective procedures
i.e., arthroplasties, spinal fusions, etc.

Prevention Strategies:
Supplemental

Redose antibiotic at 3 hr intervals in

procedures with duration >3 hours
Adjust antimicrobial prophylaxis dose for
patients who are obese (body mass index >30)
Use at least 50% fraction of inspired oxygen
intraoperatively and immediately
postoperatively in select procedure(s)
Perform surveillance for SSI
Feedback surgeon-specific infection rates

Conclusion

SSI is preventable
Prevention is the best

References

http://www.jointcommission.org/PerformanceMeasurement/
PerformanceMeasurement/SCIP+Core+Measure+Set.htm
http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html
http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfectio
ns
/
Bode LGM, et al. Preventing SSI in nasal carriers of Staph
aureys. NEJM 2010;362:9-17.
Engelmann R et al. The Society for Thoracic Surgeons
Practice Guideline Services: Antibiotic Prophylaxis in Cardiac
Surgery, Part II: Antibiotic Choice. Ann Thor Surg
2007;83:1569-76
Fry DE. Surgical Site Infections and the Surgical Care
Improvement Project (SCIP): Evolution of National Quality
Measures. Surg Infect 2008;9(6):579-84