ssi(woundcon 2016)

Prevention of Surgical Site Infections

- Dr. Jagdish Gupta Assistant Professor

Egyptians• Had some concepts about infection as they were able to

prevent putrefaction, testified by mummification skills.

• Their medical papyruses also describe the use of salves and antiseptics.

Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.2

Hippocrates (460 BC – 370 BC)

• His teachings described the use of antimicrobials, such as wine and vinegar, which were widely used to irrigate open, infected wounds before delayed primary or secondary wound closure.


Galen (130 AD – 200 AD)

• Recognised that localisation of infection (suppuration) in wounds, inflicted in the gladiatorial arena, often heralded recovery, particularly after drainage (pus bonum et laudabile).


Ignac Semmelweis (1818-1865)

• An Austrian obstetrician

• Showed that puerperal sepsis could be reduced from >10% to <2% by the simple act of HAND WASHING between cases,

• He was ignored by his contemporaries.Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.

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Joseph Lister (1827-1912)

• Applied this knowledge to the reduction of colonising organisms in compound fractures by using antiseptics.

• The principles of antiseptic surgery were soon enhanced with aseptic surgery at the turn of the century.


Alexander Fleming (1881-1955)

• The discovery of the antibiotic penicillin is attributed to Alexander Fleming in 1928, but it was not isolated for clinical use until 1941 by Florey and Chain.

• Since then, there has been a proliferation of antibiotics with broad-spectrum activity and antibiotics today remain the mainstay of antimicrobial therapy.


Surgical Site Infection Definition

• Infections of the Tissues, Organs, or Spaces exposed by surgeons during performance of an invasive procedure.

• Infections occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and affecting either the incision or deep tissue at the operation site.

F. Charles Brunicardi et al. Schwartz's Principles of Surgery, 10th Edition. McGraw-Hill Education, 2015

Surgical Site Infection• SSIs third most common HAI (Healthcare associated infection), accounting

for 14-16% of HAIs• Among surgical patients, SSIs were most common accounting for ~40% of

healthcare-associated infections • 67% incisional infections (confined to incision)• 33% organ/space infections

• Increase an average of 7 days to each hospitalization

Surgical Site Infection• While advances have been made in infection control practices

• Improved operating room ventilation• Sterilization methods• Barriers• Surgical technique • Availability of antimicrobial prophylaxis

• SSIs remain a substantial cause of • Morbidity, • Prolonged hospitalization• Death

Categories of SSI• Incisional SSI

• Superficial – skin and subcutaneous• Deep – deeper soft tissue e.g. fascia, muscles

• Organ/Space SSI• Involve any part of the anatomy (e.g. organ or space) other than incised body

wall layers, that was opened or manipulated during an operation

Pathogenesis• Microbial contamination of the surgical site is a

necessary precursor of SSI Quantitatively, it has been shown that if a surgical site

is contaminated with >105 microorganisms per gram of tissue, the risk of SSI is markedly increased.

The dose of contaminating microorganisms required to produce infection may be much lower when foreign material is present at the site.

Dose of bacterial contamination

Virulence

Resistance of the host patient

Risk of surgical site

infection

X=

Pathogenesis

Clean wounds Class I No infection is present No hollow viscus is entered Only skin microflora potentially

contaminate thewound

Class ID Wounds are similar except that a

prosthetic device (e.g., mesh or valve) is inserted

Surgical Wounds

Clean/contaminated wounds Class II A hollow viscus such as the

respiratory, alimentary, or genitourinary tracts with indigenous bacterial flora is opened under controlled circumstances

Without significant spillage of contents

Surgical Wounds

Contaminated wounds

Class III Open traumatic wounds encountered early after injury Those with extensive introduction of bacteria into a

normally sterile area of the body due to major breaks in sterile technique (e.g., open cardiac massage)

Gross spillage of viscus contents such as from the intestine, or incision through inflamed tissue

Surgical Wounds

Dirty wounds Class IV Traumatic wounds with significant

delay intreatment and in which necrotic tissue is present

Those created in the presence of overt infection (purulent material)

Those created to access a perforated viscus with high degree of contamination

Surgical Wounds

Surgical Site InfectionWound Classification Expected SSI Rates• Clean (class I) 1-4%• Clean/contaminated (class II) 6-9%• Contaminated (class III) 13-20%• Dirty (class IV) 40%

SSI Primary Risk Factors

• Endogenous microorganisms• Skin-dwelling microorganisms

• Most common source• S aureus most common isolate• Fecal flora when incisions are near the perineum or groin

• Exogenous microorganisms• Surgical personnel (members of surgical team)• Operation room environment (including air)• All tools, instruments, and materials

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

Prevention of SSI• Information for patients and carers • Pre-operative measures

Patient Ward

• Intra-operative measures Operating theatres Operating procedures

• Post-operative measures

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Information for Patients and Carers Clear, Consistent information and Advice throughout all stages of their care.

This should include the risks of surgical site infections, what is being done to reduce them and how they are managed.

How to care for their wound after discharge. How to recognise a surgical site infection and who to contact if they are

concerned. Use an integrated care pathway for Healthcare-associated infections to help

communicate this information to both patients and all those involved in their care after discharge.

• Always inform patients after their operation if they have been given antibiotics.

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NICE Guideline on Prevention and treatment of surgical site infection, National Institute for Health and Clinical Excellence, 2008.

Age Diabetes Smoking Steroid Use Malnutrition Obesity Altered immune

response

Prolonged preoperative stay Preoperative colonization with S.

aureus Perioperative transfusion Coexistent infection at a remote

body site

Patient Characteristics

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

Patient characteristics Operation

characteristics Preoperative Intraoperative Postoperative

Prevention of SSI

Diabetes• Significant relationship between increasing levels of HgA1c

and SSI rates• Increased glucose levels (>200 mg/dL) in the immediate

postoperative period (<48 hours) were associated with increased SSI risk

• Delay elective procedures until after sugar levels have been controlled

Smoking• Cigarette smoking was an independent risk factor for SSI• Nicotine use delays primary wound healing• Cessation of smoking is recommended

Steroids and immunosuppressive drugs• Patients who are receiving steroids or other immunosuppressive

drugs may be predisposed to developing SSI but the data supporting this relationship are contradictory

MALNUTRITION• Nutritional support in malnourished patients undergoing Major

surgery is initiated to decrease major morbidities associated with numerous potential complications like fascial dehisence, anastomotic leaks, etc.

• Theoretically, severe malnutrition is associated with postoperative nosocomial infections, impaired wound healing dynamics or death.

• Preoperative and/or postoperative “nutritional therapy” has not been demonstrated to reduce incisional SSI risk

PREOPERATIVE BLOOD TRANSFUSIONS• Blood transfusion apparently doubles the risk for SSI.• However, several confounding variables may have influenced

the reported association.• There is currently no scientific basis for withholding

necessary blood products from surgical patients as a means of SSI risk reduction

Patient characteristics

Operation characteristicsPreoperative Intraoperative Postoperative

Prevention

Pre-operative measures• Preoperative showering

• Advise patients to shower or have a bath using soap, either the day before, or on the day of, surgery.

• Chlorhexidine reduced bacterial colony counts nine-fold

Hair removal

• Do not use hair removal routinely to reduce the risk of surgical site infection.

• No hair should be removed unless necessary.• Increased SSI risk associated with shaving has been attributed to

microscopic cuts in the skin that later serve as foci for bacterial multiplication

• If hair has to be removed, use electric clippers with a single-use head on the day of surgery.

• Do not use razors for hair removal, because they increase the risk of surgical site infection.

Patient Skin Preparation• Most commonly used agents:

• Iodophors (e.g., povidone-iodine)• Alcohol-containing products• Biguanides (chlorhexidine gluconate)

• Alcohol is readily available, inexpensive, and remains the most effective and rapid-acting skin antiseptic.

• Aqueous 70% to 92% alcohol solutions have,germicidal activity against bacteria, fungi,and viruses, but spores can be resistant.

• One potential disadvantage is its inflammability.

Patient Skin Preparation• Both chlorhexidine gluconate and iodophors have broad spectra of

antimicrobial activity• Chlorhexidine gluconate achieved greater reductions in skin microflora

and also had greater residual activity after a single application• Povidone-iodine exert a bacteriostatic effect as long as they are present

on the skin, but may be inactivated by blood or serum proteins• No studies have adequately assessed the comparative effects of these

preoperative skin antiseptics on ssi risk in well-controlled ,operation-specific studies

Preoperative Hand antisepsis• The objective -to eliminate the transient microorganisms and inhibit

the growth of resident flora under the gloved hand at the beginning of surgery until the end of the operation.

Antiseptic agents• Agents used for surgical hand antisepsis should have the following

characteristics• Able to significantly reduce microorganisms on intact skin• Have broad spectrum activity‐• Fast acting‐• Persistent• Safe• Non irritating‐

Antiseptic agents• Preoperative surgical hand antiseptic agents• Alcohol

• Ethanol• Isopropanol• N-Propanol

• Iodophors• Povidone-iodine

• Biguanides• Chlorhexidine gluconate

Alcoholic Handrub• The antibacterial efficacy of products containing high concentrations

of alcohol by far surpasses that of any medicated soap presently available.

• Most of these studies evaluating surgical scrub antiseptics have focused on measuring hand bacterial colony counts rather than incidence SSI

• Only 1 RCT measured SSI rates, and it showed similar rates between an alcohol handrub versus a medicated soap handscrub

Aqueous antimicrobial soaps• Povidone-iodine and chlorhexidine result in significant reduction in

bacterial counts• Chlorhexidine based aqueous scrubs are more effective than povidone

iodine in lowering number of cfus on the hands• Traditionally, aqueous antimicrobial soaps require a surgical scrub with

the use of brushes.• Recently, almost all studies discourage the use of brushes.

• It can cause skin abrasions and changes in microbial flora that can lead to an increased risk of infection.

• Use brushes when the hands are visibly soiled

Pre-operative measures• Patient theatre wear

• Give patients specific theatre wear that is appropriate for the procedure and clinical setting, and that provides easy access to the operative site and areas for placing devices, such as intravenous cannulas.

• Consider also the patient's comfort and dignity.

• Staff theatre wear • All staff should wear specific non-sterile theatre wear in all areas where operations are

undertaken.

• Staff leaving the operating area • Staff wearing non-sterile theatre wear should keep their movements in and out of the

operating area to a minimum.


Surgical Attire• Scrub suits • Cap/hoods• Shoe covers• Masks• Gloves • Gowns

Pre-operative measures• Nasal decontamination

• Do not use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus routinely to reduce the risk of surgical site infection.

• Mechanical bowel preparation • Do not use mechanical bowel preparation routinely to reduce the risk of surgical site

infection.

• Hand jewellery, artificial nails and nail polish • The operating team should remove hand jewellery, artificial nails and nail polish

before operations.

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Antibiotic prophylaxis• Give antibiotic prophylaxis to patients before:

• Clean surgery involving the placement of a prosthesis or implant • Clean-contaminated surgery • Contaminated surgery.

• Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.

• Use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis.

• Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia.

• For operations in which a tourniquet is used give prophylaxis earlier NICE Guideline on Prevention and treatment of surgical site infection, National Institute for Health and Clinical Excellence, 2008.

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Antibiotic prophylaxis• Before giving antibiotic prophylaxis, consider the timing and

pharmacokinetics (for e.g., the serum half-life) and necessary infusion time of the antibiotic.

• Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.

• Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound.

• Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation.


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Suggested prophylactic regimens for operations at risk.

Norman S. Williams et al. Bailey & Love’s Short Practice of Surgery, 26th Edition. CRC Press, 2013.

Time the infusion of the initial dose of antimicrobial agent so that a bactericidal concentration of the drug is established in serum and tissues by the time the skin is incised.

The optimal time for administration of preoperative doses is within 60 minutes before surgical incision.

Antibiotic prophylaxis

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Importance of Timing of Surgical Antimicrobial Prophylaxis (AP) • Prospective study of 2,847 elective clean and clean-contaminated

procedures

• Early AP (2-24 hrs before incision): 3.8% • Postop AP (3-24 hrs after incision): 3.3% • Periop AP (< 3 hrs after incision): 1.4% • Preop AP (<2 hrs before incision): 0.6%

Maintain therapeutic levels of the antimicrobial agent in both serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room.

Intraoperative redosing is needed if the duration of the procedure exceeds two half-lives of the drug

Antibiotic prophylaxis


Operation characteristics PreoperativeIntraoperative Postoperative

Prevention

The microbial level in operating room air is directly proportional to the number of people moving about in the room.

Minimize personnel traffic during Operations

Keep the doors closed at all times

Operating Room Environment

Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas.

Positive pressure prevents airflow from less clean areas into more clean areas.


Parameters for Operating Room Ventilation• Temperature: 68o-73oF, depending on normal ambient temp• Relative humidity: 30%-60%• Air movement: from “clean to less clean” areas • Air changes: >15 total per hour

>3 outdoor air per hour

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American Institute of Architects, 1996

Perform routine cleaning of these surfaces to reestablish a clean environment after each operation.

There are no data to support routine disinfecting of environmental surfaces between operations in the absence of contamination or visible soiling.


Intra-operative measures• Sterile gowns

• The operating team should wear sterile gowns in the operating theatre during the operation.

• Gloves • Consider wearing two pairs of sterile gloves when there is a high risk of glove perforation

and the consequences of contamination may be serious.

• Antiseptic skin preparation • Prepare the skin at the surgical site immediately before incision using an antiseptic

(aqueous or alcohol-based) preparation: povidone-iodine or chlorhexidine are most suitable.

• If diathermy is to be used, ensure that antiseptic skin preparations are dried by evaporation and pooling of alcohol based preparations is avoided.

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Intra-operative measures• Diathermy

• Do not use diathermy for surgical incision to reduce the risk of surgical site infection.

• Maintaining patient homeostasis • Maintain patient temperature in line with 'Inadvertent perioperative hypothermia'

(NICE clinical guideline 65). • Maintain optimal oxygenation during surgery. In particular, give patients sufficient

oxygen during major surgery and in the recovery period to ensure that a haemoglobin saturation of more than 95% is maintained.

• Maintain adequate perfusion during surgery. • Do not give insulin routinely to patients who do not have diabetes to optimise blood

glucose postoperatively as a means of reducing the risk of surgical site infection.

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Intra-operative measures• Wound irrigation and intra-cavity lavage

• Do not use wound irrigation to reduce the risk of surgical site infection. • Do not use intracavity lavage to reduce the risk of surgical site infection.

• Antiseptic and antimicrobial agents before wound closure

• Do not use intraoperative skin re-disinfection or topical cefotaxime in abdominal surgery to reduce the risk of surgical site infection.

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Intra-operative measures• Wound dressings

• Cover surgical incisions with an appropriate interactive dressing at the end of the operation

• Polymeric Films• Opsite• Bioclusive• Tegaderm


Operation characteristics Preoperative IntraoperativePostoperative

Prevention

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Post-operative measures• Changing dressings

• Use an aseptic non-touch technique for changing or removing surgical wound dressings.

• Postoperative cleansing

• Use sterile saline for wound cleansing up to 48 hours after surgery. • Advise patients that they may shower safely 48 hours after surgery. • Use tap water for wound cleansing after 48 hours if the surgical wound has

separated or has been surgically opened to drain pus.


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Post-operative measures• Topical antimicrobial agents for wound healing by primary intention

• Do not use topical antimicrobial agents for surgical wounds that are healing

by primary intention to reduce the risk of surgical site infection.

• Dressings for wound healing by secondary intention

• Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions.

• Use an appropriate interactive dressing.


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Post-operative measures• Specialist wound care services.

• Although there is no direct evidence to support the provision of specialist wound care services for managing difficult to heal surgical wounds

• A structured approach to care (including preoperative assessments to identify individuals with potential wound healing problems) is required in order to improve overall management of surgical wounds.

• To support this, enhanced education of healthcare workers, patients and carers, and sharing of clinical expertise will be required.


Challenges in the Prevention and Management of Surgical Site Infections • Changing population of hospital patients

• Increased severity of illness• Increased numbers of surgical patients who are elderly• Increased numbers of chronic, debilitating or immunocompromising underlying

diseases• Shorter duration of hospitalization• Increased numbers of prosthetic implant and organ transplant operations

performed• Public reporting of infection rates/proportions• Growing frequency of antimicrobial-resistant pathogens• Lack of compliance with hand hygiene

THANK YOU

ssi(woundcon 2016)

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