1. Surgical Site
Infection

2. Introduction
 Ignaz Semmelweis and Joseph Lister
became the pioneers of infection control
by introducing antiseptic surgery in middle
of 19th
century.
 Since then a number of significant
developments, particularly in the field of
microbiology, have made surgery safer

3.  In 1992, the US Centers for Disease
Control (CDC) revised its definition of
'wound infection', creating the definition
'surgical site infection' (SSI) to prevent
confusion between the infection of a
surgical incision and the infection of a
traumatic wound

4. Classification
 Incisional
 organ,
 or other organs and spaces manipulated
during an operation

5. Incisional infections are further classified
into-
 superficial (skin and subcutaneous tissue)
and
 deep (deep soft tissue-muscle and fascia)

6. Microbiology of Surgical Site
Infections
 In clean surgical procedures, in which the
gastrointestinal, gynecologic, and
respiratory tracts have not been entered,
Staphylococcus aureus from the
exogenous environment or the patient’s
skin flora is the usual cause of infection

7. Factors influencing SSIs
(Lancet2000)
Surgical considerations
 Skin preparation
 Site, duration and complexity of the surgery.
 Presence of suture or foreign body
 Suturing quality.
 Pre-existing local or systemic infection
 Prophylactic atibiotic
 Haematoma
 Mechanical stress on wound

8. Anesthetic considerations
 Tissue perfusion
 Normovolaemia or hypovolaemia
 Concentration of the inspired oxygen
 Perioperative body temperature
 Pain
 Blood transfusion

9. Patient related factors
 Diabetes
 Alcoholism
 Smoking
 Poor nutrition
 Jaundice
 Obesity
 Advanced age
 Poor physical condition

10.  Surgical Factors- Decreased collagen
synthesis
 Anesthetic factors- Vasoconstriction
 Patient factors -Immunosuppression

11. Decreased tissue perfusion
Decreased PtO2
Decreased collagen Decreased neutrophil
Deposition Bactericidal activity
Decreased wound Increased wound
tensile strength Infection
Wound break down

12. Classification for operative wounds
 Clean- Elective, not emergency, non-
traumatic, primarily closed; no acute
inflammation; no break in technique;
respiratory, gastrointestinal, biliary and
genitourinary tracts not entered.
 Clean contaminated- Urgent or
emergency case that is otherwise clean;
elective opening of respiratory,
gastrointestinal, biliary or genitourinary
tract with minimal spillage (e.g.
appendectomy)

13.  Contaminated- Non-purulent
inflammation; gross spillage from
gastrointestinal tract; entry into biliary or
genitourinary tract in the presence of
infected bile or urine; major break in
technique; penetrating trauma <4 hours
old; chronic open wounds to be grafted or
covered.
 Dirty- Purulent inflammation (e.g.
abscess); preoperative perforation of
respiratory, gastrointestinal, biliary or
genitourinary tract; penetrating trauma >4
hours old.
(Ann Surgery 1964)

14. Rates of Infection
 clean 2.1%,
 clean-contaminated 3.3%,
 contaminated 6.4% and
 dirty 7.1%
US National Nosocomial Infection Surveillance (NNIS)
system

15. Prevention of SSI
 Appropriate use of antibiotics;
 Appropriate hair removal;
 Maintenance of postoperative glucose
control
 Maintenance of postoperative
normothermia

16. Antibiotics
 One dose of antibiotic to be given
preoperatively
 It is generally recommended in elective
clean surgical procedures and clean
contaminated procedures that a single
dose of cephalosporin to be administered
intravenously

17.  Involve pharmacy, infection control, and
infectious disease staff to ensure
appropriate timing, selection, and duration
of antibiotic

18. Hair removal
 Hairs to be removed in OT just before
surgery.
 Use of clippers than razors reduces the
chances of infection

19. Glucose control
 Implement a glucose control protocol.
 Develop one protocol to be used for all
surgical patients.
 Regularly check preoperative blood glucose
levels on all patients to identify
hyperglycemia;
 Assign responsibility and accountability for
blood glucose monitoring and control.

20. CDC surgical site infections
prevention guidelines, 1999
 Category 1A- Strongly recommended for
implementation and supported by well-
designed experimental, clinical, or
epidemiologic studies
 Treat remote infection before elective
operation;
 Postpone surgery until treated;

21.  Do not remove hair from operative site
unless necessary to facilitate surgery; If
hair is removed, do immediately before
surgery, preferably with electric clippers
 Select an antimicrobial agent with
efficacy against expected pathogen;
 Intravenous route used to ascertain
adequate serum levels during operation
and for at most a few hours after incision
closed

22.  Category 1B- Strongly recommended for
implementation and supported by some
experimental, clinical, or epidemiologic
studies and strong theoretical rationale
 Control serum blood glucose perioperatively;
 Cessation of tobacco use 30 days before
surgery;
 Do not withhold necessary blood products to
prevent SSIs

23.  Shower or bath on night before operative
procedure;
 Wash incision site before performing
antiseptic skin preparation with approved
agent
 Do not routinely use vancomycin for
antimicrobial prophylaxis

24.  Category II- Suggested for implementation
and supported by suggestive clinical or
epidemiologic studies or theoretical
rationale
 Prepare skin in concentric circles from
incision site;
 Keep preoperative stay in hospital as short
as possible

25. Superficial incisional surgical
site infections
 occur within 30 days of procedure
 involve only the skin or subcutaneous tissue
around the incision.

26.  purulent drainage from the incision
 organisms isolated from an aseptically
obtained culture of fluid or tissue from the
incision
 at least one of the following signs or
symptoms of infection - pain or
tenderness, localised swelling, redness or
heat - and the incision is deliberately
opened by a surgeon, unless the culture is
negative

27. Don’t considered superficial SSIs
 stitch abscesses
 infection of an episiotomy or neonatal
circumcision site
 infected burn wounds
 incisional SSIs that extend into the fascial
and muscle layers

28. Deep incisional surgical site
infections
 occur within 30 days of procedure (or one
year in the case of implants)
 are related to the procedure
 involve deep soft tissues, such as the
fascia and muscles.

29.  purulent drainage from the incision but not
from the organ/space of the surgical site
 a deep incision spontaneously dehisces or is
deliberately opened by a surgeon when the
patient has at least one of the following signs
or symptoms - fever (>38°C), localised pain
or tenderness - unless the culture is negative
 an abscess or other evidence of infection
involving the incision is found on direct
examination or by histopathologic or
radiological examination
(CDC definitions of surgical wound infections )

30. Wound assessment
 ASEPSIS –to assess wounds resulting
from cardiothoracic surgery
 Southampton Wound Assessment Scale –
categorized according to any complications
and their extent

31. ASEPSIS wound scoring system

33.  Score 0-10-satisfactory healing
 11-20-disturbance of healing
 20-30-minor wound infection
 31-40-moderate wound infection
 >41-severe wound infection

34. Southampton scoring system
Grade Appearance
 0 Normal
 I Normal healing with mild
bruises and erythema
 A Some bruising
 B considerable
brusing
 C Mild erythema

35. Grade Appearance
 II Erythema plus other signs
of infection
 A At one point
 B Around sutures
 C Along wound
 D Around wound

36. Grade Appearance
 III Clean or haemoserous
discharge
 A At one point only
 B Along wound
 C Large volume
 D Prolonged

37. Grade Appearance
 IV Major wound
complication like pus
 A At one point only
 B Along wound
 V Deep or severe
infection with or without
breakdown

38. Treatment
 Surgical debridement of wound and
antibiotics according to sensitivity

39. Thank you