˘ ˇ ˇmedinfo2.psu.ac.th/surgery/edu_be_document/document4/surgical... · surgical site...
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Surgical Site Infections (SSIs)
� Postoperative infections presenting at any level
* Incisional superficial (skin, subcutaneous tissue)
* Incisional deep (fascial plane and muscles)
* Organ/space related (anatomic location of the procedure
itself) : Intra-abdominal abscesses, empyema,
mediastinitis
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Surgical Site Infections (SSIs)
� Most common nosocomial infection
� Present anytime from 0-30 days after operation or up
to 1 year after implantation foreign material
� 60-80% of SSIs is incisional infection
� Organ/space related SSIs accounting 93% mortality
� Staphylococcus aureus is the most common pathogen
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Causes and Risk Factors
� Bacterial factors
* Virulence : toxin, capsules
* Bacterial load (>105) : infection become evidence
clinically for 5 days or longer after operation
* Remote site infection
* Length of preoperative stay
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Causes and Risk Factors
� Bacterial factors
* Duration of procedure
* Wound class
* Intensive care unit patient
* Prior antibiotic therapy
* Preoperative shaving
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Causes and Risk Factors
� Local wound factors
* Good surgical technique is the best way to avoid SSI
� Patient factors
* Age, Cigarette smoking
* Immunosuppression, Steroids, Malignancy
* Obesity, Diabetes, Malnutrition, Comorbidities
* Transfusions, Oxygen, Temperature, Glucose control
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Surgical Wound Classification
� Clean (1-5%) uninfected operative wound, no inflammation,
not entered respiratory, alimentary, genital or infected urinary tract
� Clean-contaminated (3-11%) entered respiratory, alimentary,
genital or urinary tract under controlled
� Contaminated (10-17%) major breaks in sterile technique or
gross spillage from gastrointestinal tract
� Dirty (27%) organisms causing infection were present in
operative field before operation
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Surgical Wound Classification
Drainage abscess, Perforated bowel, PeritonitisDirty / infected
Surgery for inflamed appendicitis, Bile leakage during
cholecystectomy, Diverticulitis
Contaminated
Cholecystectomy, Appendectomy
Small bowel resection, Whipple operation, TUR-P
Clean / contaminated
Mastectomy, Herniorrhaphy, Thyroidectomy,
Neck dissection, Vascular surgeries
Clean
Procedure type Classification
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SSI Risk Scores
� Wound class : contaminated or dirty wound
� ASA : III, IV, V
� Duration of operation > 75th percentile
Number of Positive Risk Factors Risk of SSI (%)
0 1.5
1 2.9
2 6.8
3 13
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Prevention
� Aseptic and antiseptic technique
� Prophylactic antibiotics
� Surveillance programs
� Focuses on controlling the bacterial factors
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Aseptic and Antiseptic Methods
� Environmental and architectural of OR
� Surgical site preparation
� Scrubbed hands and forearms for at least 5 minutes
� Double-gloving
� Instruments should be sterilized
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Prophylactic antibiotics
� No substitute for careful surgical technique
� Not indicated for clean wound and no foreign body
has been controversial (breast, hernia)
� Started 0.5-1 hr before surgery, no benefit if started
after that
� Never use more than 24 hr after elective surgery
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Prophylactic antibiotics
� Determinant the procedure is expected to enter
� If anaerobic flora are not expected , cefazolin is the
drug of choice
� Clindamycin for patients who are allergic to
cephalosporins
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Local Wound Related
� Good judgment and surgical technique
* Vascular supply, Adequate control bleeding
* Complete debridement, Remove foreign bodies
* Monofilament, Suture used only when required
* Close dead space, Close-suction drain system
* Delayed primary closure, Isolate from environment 48-
72 hr
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Patient Related
� Correction or control of underlying defect
� Optimizing nutritional status
� Higher partial pressure of oxygen (high FiO2)
� Preoperative warming
� Maintain glucose levels 80-110 mg/dL
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Specific Surgical Infections
� Primary principle treating surgical infections is
source control
* Drainage of infection, correction of predisposing cause
� Antibiotic treatment and systemic support are only
adjunctive therapies
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Soft Tissue Infections
� Abscess
* Necrotic center (pus) without blood supply, surrounded
by a vascularized zone of inflammatory tissue
* Will not resolve unless the pus is drained and evacuated
� Cellulitis
* Intact blood supply and viable tissue
* Resolves with appropriate antibiotic therapy alone
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Soft Tissue Infections
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Soft Tissue Infections
� Most common caused by S. aureus often combined
with streptococci
� Wound older than 6 hr, significant contamination,
necrotic tissue, puncture wound, crush mechanism or
avulsion should not be closed
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Tetanus
� Caused by Clostridium tetani
� Mortality rate ~ 50% even treated
� Prevented by toxoid and immunoglobulin, not
antibiotics
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Tetanus
� Tetanus toxoid 0.5 mL IM 3 doses (0,1,6 months)
* Covered for 10 years
* Given in patients with non-immunized, incomplete, >10
yrs or unknown history
* Booster single dose if completed immunized 5-10 yrs.
� TAT (TIg) in dirty wound, 3000 u im or sc, test
allergy before use
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Postoperative Wound Infection
� Usually occur on day 3rd - day 7th
� Painful, red, warmth, tender and purulent discharge
from wound
� Stitch off, pus drainage and wet dressing until clean,
then resuture (delayed primary closure)
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Postoperative Wound Infection
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Postoperative Wound Infection
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Necrotizing Soft Tissue Infections
� Less common but serious conditions
� Absence of clear local boundaries or palpable limits
� Presence of gas in soft tissue infection implies
anaerobic metabolism like gas gangrene
� Most common pathogens : clostridium perfringens,
B-hemolytic S. pyogenes
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Necrotizing Soft Tissue Infections
� Rapid progressing of soft tissue infection, marked
hemodynamic response, failure to respond to
conventional nonoperative therapy
� ecchymoses, bullae, dermal gangrene, extensive
edema, crepitus
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Necrotizing Soft Tissue Infections
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Necrotizing Soft Tissue Infections
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Necrotizing Soft Tissue Infections
� Treatment always include debridement, broad-
spectrum antibiotics and monitoring and systemic
support
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Necrotizing Soft Tissue Infections
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Necrotizing Soft Tissue Infections
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Necrotizing Soft Tissue Infections
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Intra-abdominal and Retroperitoneal Infections
� Fever, tachycardia, hypotension, catabolic response,
MOF is the caused of death
� Outcome is improved by early diagnosis and
treatment
� Treatment consists of cardiorespiratory support,
antibiotic therapy, and operative intervention
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Intra-abdominal and Retroperitoneal Infections
� Goal of operative intervention is to correct the
underlying anatomic problem
� Foreign material and fibrin should be removed,
abscess requires drinage (PCD, open)
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Retroperitoneal Infections
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Retroperitoneal Infections
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Intra-abdominal Infections
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Intra-abdominal Infections
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Prosthesis Device-Related Infections
� Staphylococcus epidermidis
� Intensive antibiotic therapy, removal of infected
device under antibiotic cover, replacement with a
new uninfected device followed by prolong antibiotic
treatment when device is life sustaining
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Nonsurgical Infectios in Surgical Patients
� Most common is urinary tract infection
* Use for specific indications and short durations
* Strict closed-drainage techniques
� Lower respiratory tract infections
* Abnormal chest radiographic findings, abnormal ABG
* Bronchoalveolar lavage diagnose ventilator-associated
pneumonia
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Nonsurgical Infectios in Surgical Patients
� Catheter infection
* Erythema, warmth, tenderness, pus at site of insertion
* Require removal of catheter, if new central line is
needed, a new puncture is warranted
* Routine change of central line not proven to reduce
infection rates
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Postoperative Fever
� Most febrile postoperative patients are not infected
� Fever in the first 3 days after operation most likely
noninfection
� 2 important infectious causes of fever in the first 36
hr. after laparotomy
* Injury to bowel with intraperitoneal leak
* B-hemolytic streptococci or clostridial infection
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Antimicrobials
� General principles
* Achieve levels of antibiotic at the site of infection that
exceed the minimum inhibitory concentration for the
pathogens present
* Mild infections can handled on outpatient with oral
antibiotics
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Antimicrobials
� General principles
* Surgical infections is not a specific duration of
antibiotics known to be ideal
* Clinical improved and normal temperature for 48 hr can
switches to oral antibiotics
* WBC.may not have returned to normal
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Antimicrobials
� Antibiotic for empiric treatment
* Coverage the presumed microorganisms
* Able to reach the site of infection
* Toxicity should be considered
* Dosed aggressively
* Set a time limit for the period for the antibiotic will be
given
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HIV precaution
� Universal testing
* Costly and unable to do in every cases
* Problem of window period
� Universal precaution
* Avoid direct contact with any body fluid
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