Surgical site infections

DR BASHIRU AMINU
 outline

Introduction
Definition
Historical perspective
Epidemiology
pathogenesis
aetiology
Classification
Clinical features
Management
conclusion
 introduction

Surgical site infections continue to be a major

challenge
in spite of various advances in science
It is responsible for significant increase in mortality ,
morbidity &hospital stay
This means more expenditure
 definitions

Infection occurring at site of operation or surgical

tract within thirty days of surgery or one year ff
implant surgerys
 Historical perspective

Edwin smith(circa 1600 bc), ebers papyrus(circa

1534)
Hippocrates (460ad-377bc)
Galen laudable pus theory
14th century at the time of ambrose pare(1510-1590)
Koch (1843-1910) recognized septic foci as result of
microbial growth
Semmelweis(1818-1865) reduction in puerperal
sepsis
Pasteur revolutionarized concept of wound infection
Lister(1827-1912) used carbolic acid
Antoine depagne(1862-1925) reintroduced
debridment & delayed closure
Alexander fleming(1881-1955)of penicillin
Halsted introduced rubber gloves to his scrub nurse
who allergic to materials used in sterilizing
instruments
His student J. bloodgood made it routine use
 epidemiology

 frequency of SSI difficult to monitor

A survey by WHO infections varying from 3-21%,
with wound infections accounting for 5-34% of the
total.
The 2002 report (NINSS) Oct 97 and Sept 2001,
shows rates of 10% costing1 billion pounds annually.
75% of deaths in surgical patients is related to SSI
Actual estimates difficult to make here due to paucity
of data
 pathogenesis

With incision on skin 5 critical initiators of

inflammatory response are activated
 Coagulation proteins
 platelets
part of the hemostatic mechanism
herald the onset of inflammation.
Mast cells ,complement proteins
 bradykinin is produced from protein precursors.
 The net effect of 5 factors is vasodilation and
increased blood flow
products from 5 initiators result in nonspecific
chemoattractant signals,
 mast cells produce specific chemokine signals that
"draw" specific neutrophil, monocyte, etc
The point is that tissue injury initiates mobilization
of phagocytes into the wound before contamination
occurs
 aetiology

All surgical wounds are contaminated

most cases, infection does not develop because host
defenses are efficient
A complex interplay between host, microbial, and
surgical factors
ultimately determines prevention or establishment
infection.
Factors that affect surgical wound healing are
classified below 
 microbiology

 Microbial factors are;

 the dose of inoculum,
 virulence,
Microenvironment
impaired host defenses
 patient's own endogenous flora
The traditional microbial concentration is bacterial
counts higher than 10,000 organisms per gram of
tissue (or in the case of burned sites, organisms per
cm2 of wound).
 largest inoculum is structure ordinarily heavily
colonized eg bowel.
 distal small intestine and colon have large concn of
bacteria with 103 - 104 bacteria/mL of distal small
bowel content,
 105 - 106 bacteria/mL in the right colon, and 1010 -
1012 bacteria/g of stool in the rectosigmoid colon.
Large amts also present in stomach of older patients
with hypo- or achlorhydria.
Significant concn in biliary tract when patients are
over 70 years of age
 or have obstructive jaundice etc
Procedures in female genital tract will encounter 106
- 107 bacteria/mL.
Procedures in oropharynx, lung, or urinary tract
have significant contaminants
Notably, SSIs are generally consequence of intra
operative contamination
The most bacteria responsible for SSIs
Staphylococcus aureus.
The emergence of resistant strains considerably
increased burden of morbidity and mortality
skin and mucosal surfaces ; gram-positive cocci
(notably staphylococci)
G-ve aerobes and anaerobic bacteria contaminate
skin in the groin/perineal areas.
Contaminants in GIT surgery are bowel flora
 which include g-ve bacilli (eg, E coli), g+s,
enterococci
G+ particularly staph & strep are main exogenous
flora in SSIs.
Sources of such pathogens include ;
surgical/hospital personnel
 intra operative circumstances, instruments,
operating room air.
Methicillin resistant Staphylococcus aureus (MRSA)
 MRSA colonize skin ,body of individual without
causing sickness,
 this way, it can be passed on to other individuals
Systemic factors include;
 age, malnutrition, hypovolemia, poor tissue
perfusion
 obesity, diabetes, steroids,
Immuno suppressants.
Wound characteristics include;
 nonviable tissue in wound; hematoma;
foreign material, including drains and sutures;
dead space; poor skin prep +shaving
 and preexistent sepsis (local or distant).
Operative chrxs include poor surgical technique;
lengthy operation (>2 h);
intraoperative contamination, eg theater staff and
instruments
inadequate theater ventilation;
prolonged preop stay
hypothermia.
The type of procedure is a risk factor.
Vacuum-assisted wound closure
 classification

Various classifications
traditional developed in wake of uv light study of
1964
Primarily to provide clinical estimate of inoculum of
bacteria
 does not take into cognisance factors like;
 virulence, host defences, microenvironment of the
wound
Clean Wounds
does not enter into a colonized viscus or lumen
 eg elective inguinal hernia repair
 SSI risk is minimal
common pathogen is Staphylococcus aureus
 SSI rates is 2% or less
Clean-Contaminated Wounds
 enters colonized viscus or cavity under elective
 contaminants are endogenous bacteria
Eg sigmoid colectomy wounds contain E coli and
Bacteroides fragilis
Elective intestinal resection, pulmonary resection,
gynecologic procedures, and head-neck cancer op in
oropharynx are examples
 Infection rates in the range of 4% to 10%
Contaminated Wounds
 gross contamination present in absence of obvious
infection.
 eg laparotomy for penetrating injury +intestinal
spillage
 contaminants bacteria introduced by gross soilage
Infection rates greater than 10%
Dirty Wounds
 active infection is already present
 Abdominal exploration for acute bacterial
peritonitis and intra-abdominal abscess are
examples
 Pathogens those of active infection
Unusual pathogens are seen
Esp if infection occurred in hospital or nursing home
setting
 US CDC developed the NNIS Risk Index system
 member hospitals report cumulative data.
A risk index developed to include ;
traditional wound classification system defined
above and additional variables.
 This simplified risk index has a range from 0 to 3
points.
 A point is added to the patient's risk index for each
of the following 3 variables:
 This simplified risk index has a range from 0 to 3
points.
 A point is added to the patient's risk index for each
of the following 3 variables
1 point - the patient had operation classified as either
contaminated or dirty.

1 point - the patient has an ASA preoperative

assessment score of 3, 4, or 5

1 point - the duration of operation exceeds the 75th

percentile
 standard T point (75% percentile) determined from
NNIS database
the T point defined as length of time in hours that
represents the 75th percentile of procedures
Table 1. Physical Status Classification for
Surgical Patients
Class I A patient in normal health
Class II A patient with mild systemic disease
resulting in no functional limitations
Class III A patient with severe systemic disease that
limits activity, but is not incapacitating
Class IV A patient with severe systemic disease that
is a constant threat to life
Class V A moribund patient not likely to survive 24
hours
 Operation T Point (hrs)
s

Operation T Point (hrs)

 Coronary artery bypass graft 5
 Bile duct, liver, or pancreatic surgery 4
 Craniotomy 4
Head and neck surgery 4
Colonic surgery 3
 Joint prosthesis surgery 3
 Vascular surgery 3
Abdominal or vaginal hysterectomy 2
Ventricular shunt 2
Herniorrhaphy 2
 Appendectomy 1
 Limb amputation 1
 Cesarean section 1
 newer definitions of superficial incisional SSI, deep
incisional SSI, and organ space SSI
This methodology, + NNIS Risk Index, allows
recognition of SSI rates + classification of severity.
Reporting of data stratified by risk and severity
 Superficial Incisional SSI

Occurs within 30 days after the operation;

Involves only the skin or subcutaneous tissue; and

At least 1 of the following:

 Purulent drainage (culture documentation not required)

 Organisms isolated from fluid/tissue of superficial incision

 At least 1 sign of inflammation (eg, pain or tenderness,

induration, erythema, local warmth of the wound)
Deep Incisional SSI
Occurs within 30 days of operation or within 1 year if an
implant is present;

Involves deep soft tissues (eg, fascia and/or muscle) of

the incision; and

At least 1 of the following:

Purulent drainage from deep incision minus
organ/space involvement

Fascial dehiscence or fascia separated by the surgeon

Deep abscess identified by during reoperation,

histopathology, radiologically

Surgeon declares deep incisional infection is present.

 Wound is deliberately opened by the surgeon

 Surgeon or attending physician declares the wound infected.

 Organ/Space SSI

Organ/Space SSI
Occurs within 30 days of operation or within 1 year if an
implant is present;

Involves structures not opened or manipulated operation

At least 1 of the following:

Purulent drainage from a drain placed by a stab wound

Organisms isolated from organ/space by aseptic culturing

technique

Identification of abscess in the organ/space by direct examination,

during reoperation, or by histopathologic or radiologic
examination

Diagnosis of organ/space SSI by surgeon

wound grading Southampton system
0 – normal healing
1 – normal healing with mild bruising/erythema
2 – Erythema + other signs of inflammation
3- Clear or heamoserous discharge
4- Pus
5-Deep or severe wound infection with or without
tissue breakdown
 ASEPSIS wound score

Additional treatment
Antibiotic for wound infection 10
Drainage of pus under LA 5
Debridement of wound under GA 10
Serous discharge Daily 0-5
Erythema Daily 0-5
Purulent exudation Daily 0-10
Separation of deep tissues Daily 0-10
Isolation of bacteria 10
Stay greater than 14 days 5
 Clinical features

Most have been mentioned along line

Local features which vary depending on stage, type
Erythema , swelling, discharge, gaping wound,
dehiscence
Systemic symtoms; fever, weight loss from increased
catabolic loss
Major wound infection
defined as a wound that either discharge significant
quantity of pus spontaneously or secondary
procedure to drain it +/- systemic signs
Minor wound infections
this may discharge pus or infected serous fluid but
not excessive s
 Systemic manifestations

Sepsis is the systemic manifestation of a

documented infection
SIRS is the body systemic response to an infected
wound
MODS is the effect that the infection has on the
whole body
MSOF is the end stage of uncontrolled MODS
 management

Detailed history
Thorough physical examination
Relevant investigations
Gram stain
Culture (both aerobic and anaerobic)
Sensitivity testing
Antigen and antibody testing
Detecting of RNA and DNA sequencing
PCR
Staining methods;Gram stain
Staining for fungal elements
Culture techniques
Fungal cultures can be requested
 Isolation of single colonies allows further growth
and identification of the specific organism.
 Sensitivity testing then follows mainly for aerobic
organisms.
Newer techniques ELISA, radioimmunoassay
Detection of antibody in host sera
Detection of RNA or DNA sequences by Northern,
Southern, or Western blotting, respectively
Polymerase chain reaction (PCR)
FBC, FBS, U/E,SERUM PROTEINS
Imaging Studies
Ultrasound can be applied to the infected wound
area to assess whether any collection needs drainage.
MRI, CT SCAN
 TREATMENT

Local
-Drainage
-Debridement
Systemic
-resuscitation
-appropriate antibiotics
 prevention

Principles
Specific 1- removal of source of infection
2 - block transfer
3 - increase patient resistance
General 1- Infrastructure
theatre design
2 - Administrative policies
antibiotic policies
patients to shower and scrub the surgical site with
antiseptic soap
 dont shave or clipp evening before operation.
 Nicks and scrapes result in colonization
Depilatory agents recommended
occasionally result in a hypersensitivity
The presence of open skin wounds or infection of the
hands or arms of the surgeon makes postponement
of the operation desirable.
 If the patient has any preexisting infection, SSI will
be more likely.
Prevention in the OR begins with the skin
preparation
 The site is cleansed with chlorhexidine or
povidone iodine.
Isopropyl alcohol has excellent antiseptic qualities
but is undesirable because of its flammability
 Povidone iodine should be allowed to dry before the
incision
use of caps, gowns, masks, and sterile surgical
gloves.
Double gloving prevents blood "strike through" onto
the surgeon's hands
Avoid blood ,fluid breakthrough especially on
surgeon's forearms
Avoid wet drapes
 replace soaked gown &drapes.
 Wide areas of skin prep around surgical site reduces
risk of breakthrough
Gas sterilization of instruments after thorough
cleansing of any particulate matter
Bowel prep
 Achieving hemostasis at the surgical site is
important
 process of controlling bleeding may itself increase
infection.
 HB in soft tissues or wound space Is potent stimulus
to microbial multiplication
 exuberant use of electro cautery leaves necrotic
tissue
Prophylactic antibiotics
Reduces incidence of post-op wound infections
Directed against likely bacteria
Given 30-60mins before operation
Repeated if operation >4hours
– Incision should destroy as little tissue as possible(incision
made through entire skin layer)
- Tissue plane divided with few passes of the knife always
beginning a new pass in the depths of the wound
– Ensure bleeding has stopped before closing wound
 Avoid wound edge desication
 Proper wound edge apposition
 Use of few sutures