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BASIC CONCEPT OF SURGICAL SITE INFECTION (SSI) Ali Sungkar Divisi Fetomaternal,Departemen Obstetri dan Ginekologi FKUI/RSUPN - CM

Criteria  for  defining  SSIs

1999. Infect Control Hosp Epidemiol 1999;20:247-280.

}  Superficial incisional }  (skin or subcutaneous tissue) }  Infection ≤30 days after procedure and at least 1 of

the following: –  Purulent drainage from superficial lesion/organisms

isolated aseptically

–  At least 1: pain/tenderness, swelling, redness, heat

–  Superficial incision deliberately opened by surgeon unless culture negative

}  or SSI diagnosed by surgeon or attending physician

Defining Surgical Site Infections

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press.

All rights reserved.

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Deep incisional (deep soft tissue at incision site)

•  Infection ≤30 days after procedure (no implant) or ≤1 year (with implant) plus at least 1 of of the following: – Purulent drainage from deep in incision but not

from organ/space – Spontaneous dehiscence or surgical opening of

deep incision with fever, pain, or tenderness – Abscess or other evidence of infection involving

deep incision

•  or SSI diagnosed by surgeon or attending physician

Defining Surgical Site Infections (cont.)

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of

Chicago Press. All rights reserved.

Organ/space (any site other than incision)

•  Infection ≤30 days after procedure (no implant) or ≤1 year (with implant) plus at least 1 of the following: –  Purulent drainage from a drain placed through a

stab wound into organ/space –  Organisms isolated from a culture of fluid or

tissue –  Abscess or other evidence of infection involving

the organ/space found by histopathologic examination, X-ray, or reoperation

•  or SSI diagnosed by surgeon or attending physician

Defining Surgical Site Infections (cont)

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press. All

rights reserved.

Class 1 – Clean ü  Uninfected operative wound, no inflammation

Class II – Clean-Contaminated ü  Alimentary tract (and others), under controlled

conditions without unusual contamination

Class III – Contaminated ü  Major breaks in sterile technique, eg, gross

spillage from the gastrointestinal tract ü  Incisions encountering acute inflammation

Class IV – Dirty-Infected ü  Old traumatic wounds with dead tissue, infection,

perforated viscera

Surgical Wound Classification

Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

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National Nosocomial Infections Surveillance System (NNIS)

Classification Wound Class SSI Risk

Clean 0 Lower

Higher

Clean-contaminated: GI/GU tracts entered in a controlled manner

1

Contaminated: open, fresh, traumatic wounds infected urine, bile gross spillage from GI tract

2

Dirty-infected:

3

n  Increasing proportion of SSIs: à Antimicrobial-resistant

pathogens, MRSA……

n  Unusual pathogens à  Rhizopus oryzae à  Clostridium perfringens à  Rhodococcus bronchialis à  Nocardia farcinica à  Legionella pneumophila and

Legionella dumoffii à  Pseudomonas multivorans

Microbiology

From Weiss CA, Statz CI, Dahms RA, et al: Six years of surgical wound surveillance at a tertiary care center. Arch Surg 134:1041,

Wound classification Patient factors Environmental factor

Clean Diabetes Preoperative antiseptic showering

Clean-contaminated

Obesity Preoperative hair removal

Contaminated Nicotine use Patient skin preparation

Dirty Steroid use Preoperative hand/forearm antisepsis

Malnutrition Antimicrobial prophylaxis Hospital stay h

Nares colonization with S. aureus Transfusion

Risk  and  prevention

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The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

Agent Mechanism of action

Gram positive bacteria

Gram negative bacteria

Rapidity of action

Residual activity

Alcohol Denature proteins

Excellent Excellent Most rapid Non

Chlorhexidine Disrupt cell wall

Excellent Good Intermediate Excellent

Iodine/ Iodophors by free iodine

Oxidation/ substitution

Excellent Good Intermediate Minimal

PCMX Disrupt cell wall

Good Fair Intermediate Good

Triclosan Disrupt cell wall

Good Good Intermediate Excellent

Mechanism and Spectrum of Activity for Commonly Used Antiseptics

Active Agents PI CHG CHG + Alc

Broad Spectrum X X X

Rapid Activity X

Residual Activity X X

Activity in Blood/Organic X X

Non-Irritating X X X

Toxic/Minimal Absorption X X X

PI = povidone iodine CHG = chlorhexidine gluconate Alc = alcohol (70%)

Perioperative Skin Preparation: A Comparison

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n  The risk of SSI can be conceptualized :

n  Dose of bacterial contamination x virulence Resistance of the

host patient = Risk of surgical site infection

n  Surgical site: >105 microorganisms/gram of tissue

n  Endotoxin: gram-negative bacteria

g stimulates cytokine production

g systemic inflammatory response syndrome

n  Exotoxin: certain strains of clostridia & streptococci

g disrupt cell membranes

Pathogenesis

n  Most common source: endogenous flora of the patient’s skin, mucous membranes, or hollow viscera.

g Staphylococcus aureus g Coagulase negative staphylococci n  Gastrointestinal organ: g E.coli g Enterococci g Bacillus fragilis n  Exogenous sources: g Surgical personnel or Operating room environment g Flora: Staphylococci and streprococci n  Fungi: rarely cause SSIs

Pathogenesis

Sabiston Textbook of Surgery, 18th ed.

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Endogenous: patient’s skin or mucosal flora •  Increased risk with devitalized tissue, fluid collection,

edema, larger inocula

Exogenous •  Includes OR environment/instruments, OR air, personnel

Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection

•  May occur days to weeks following the procedure Most infections occur due to organisms implanted during the procedure

Sources of SSIs

Surgical infection prevention

•  SSI rates •  Appropriate prophylactic antibiotic chosen •  Antibiotic given within 1 hour before

incision •  Discontinuation of antibiotic within 24

hours of surgery •  Glucose control •  Proper hair removal •  Normothermia in colorectal surgery

patients

Performance Measures

n  Diabetes g Controversial g Patients underwent CABG @ Increasing levels of HbA1c and SSI rates @ Increased glucose levels (>200 mg/dL)

n  Nicotine use g Delays primary wound healing g Increase the risk of SSI

n  Steroid use g Controversial

Patient  characteristics

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n  Malnutrition g Theoretical arguments: increase the SSI risk g Two randomized clinical trials: preoperative “nutritional therapy” did not reduce incisional and organ/space SSI risk.

n  Prolonged preoperative hospital stay n  Preoperative nares colonization with S. aureus

g Mupirocin ointment: Controversial n  Perioperative transfusion

g No scientific basis

Patient  characteristics

•  Preoperative antiseptic showering •  Preoperative hair removal •  Patient skin preparation in the operating

room •  Preoperative hand/forearm antisepsis •  Antimicrobial prophylaxis

Operative  characteristics  :  Preoperative  issues

n  Preoperative  antiseptic  showering  g  Decreases  skin  microbial  colony  counts  g No  evidance  of  benefit  to  reduce  SSI  rates    

n  Preoperative  hair  removal g  Shaving:          @  immediately  before  the  operation:  SSI  rates  3.1%          @  shaving  within  24  hours  preoperatively:  7.1%          @  having  performed  >24  hours:  SSI  rate  >  20%.    g  Depilatories:            @  lower  SSI  risk  than  shaving  or  clipping            @  hypersensitivity  reactions

Operative characteristics : Preoperative issues

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n  Patient skin preparation in the operating room g Most common used: Alcohol solutions Chlorhexidine gluconate Iodophors

n  Preoperative hand/forearm antisepsis

Operative  characteristics  :  Preoperative  issues

1999. Infect Control Hosp Epidemiol 1999;20:247-280.

}  Operating room environment g  Ventilation

@ Positive pressure with respect to corridors and adjacent areas

g  Environmental surfaces @ Rarely implicated as the sources of pathogens important in the development of SSIs. @ Important to perform routine cleaning of these surfaces g Conventional sterilization of surgical instruments @ Inadequate sterilization of surgical instruments has resulted in SSI outbreaks

Operative  characteristics  :  Intraoperative  issues

}  Surgical attire and drapes g The use of barriers: @ Patient: minimize exposure to the skin, mucous membranes, or hair of surgical team members @ surgical team members: protect from exposure to blood and bloodborne pathogens.

}  Asepsis and surgical technique g Rigorous adherence to the principles of asepsis by all

scrubbed personnel g Excellent surgical technique: reduce the risk of SSI. g Drains: increase incisional SSI risk.

Operative  characteristics  :  Intraoperative  issues

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}  Incision care à The type of postoperative incision care @ Closed primarily: the incision is usually covered with a sterile dressing for 24 to 48 hours. @ Left open to be closed later: the incision is

packed with a sterile dressing. @ Left open to heal by second intention: packed

with sterile moist gauze and covered with a sterile dressing.

Operative  characteristics  :  Postoperative  issues

Treatment  surgical  site  infection            g  Efflux  of  purulent  material  and  pus          g  Fascia  is  intact:                    debridement                  Irrigated  with  N/S  and                    packed  to  its  base  with  saline-­‐moistened  gauze          g  Fascia  separated:  drainage  or  reoperation    Most  SSIs:  healing  by  secondary  intention  

Operative  characteristics  :  Postoperative  issues

}  Discharge  planning  

g  The  intent  of  discharge  planning:  

       @  maintain  integrity  of  the  healing  incision,    

       @  educate  the  patient  about  the  signs  and  symptoms    

                 of  infection,    

       @  advise  the  patient  about  whom  to  contact  to  report    

                 any  problems.  

Operative  characteristics  :  Intraoperative  issues

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1. SSI risk stratification 2. SSI surveillance methods

a.  Inpatient SSI surveillance b.  Postdischarge SSI surveillance

SSI  Surveillance

}  SENIC risk index: 1)  An abdominal operation, 2)  An operation lasting >2 hours, 3)  A surgical site with a wound classification of

either contaminated or dirty/infected 4)  An operation performed on a patient having

>3 discharge diagnoses.

SSI  risk  stratification

The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE

(+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

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Inpatient SSI surveillance (1) Direct observation of the surgical site:

g  surgeon, g  trained nurse surveyor, g  Infection control personnel

the most accurate method to detect SSIs

(2) Indirect detection: g  review of laboratory reports, g  Patient records, g  discussions with primary care providers

SSI  surveillance  methods

•  Patient questionnaires •  Surgeon questionnaires •  Nurse observation of the wounds at

patient’s home or during a routine postoperative visit

Postdischarge SSI surveillance

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Resources for Implementation WHO Surgical Safety Checklist

World Health Organization. Safe Surgery Saves Lives http://www.who.int/patientsafety/safesurgery/en/ Accessed 19 Nov 2009

q  Criteria for defining SSIs q  Surgical wound classification q  SSI risk factor:

o  Patient factor o  Operative factors o  Surgical wound classification

q  Antimicrobial prophylaxis q  Treatment surgical site infection q  SSI surveillance methods

Take Home Message

Terima Kasih