surgical site infection& amp dr. anil ganju
TRANSCRIPT
Surgical site infections &
AMP
Dr. Anil Ganju
Surgical Site Infections (SSI)
Def: Infections that occur in the wound created by an invasive surgical procedure .
Most important causes of HCAIs. (14-16% )
Most common surgical patient nosocomial infection (38%)
Over 1/3rd of postoperative deaths are related to SSI.
Deaths in patients with nosocomial infections—77% related to infection.
2/3 involved surgical incision, 1/3 deep structures accessed by incision
SSIs, Soft tissue/wound infections
Range from a relatively trivial wound discharge with no other complications to a life-threatening condition.
Considerable morbidity
poor scars that are cosmetically unacceptable, hypertrophic or keloid, persistent pain and itching, restriction of movement, impact on emotional wellbeing
SSI can double the length of time a patient stays in hospital and thereby increase the costs.
SSI – Surgery Classification
1. Clean Surgeries
2. Clean contaminated
3. Contaminated
4. Dirty infected
SSI – Wound Classification
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Class I (clean)
Atraumatic wound w/o inflammation. No respiratory, GU,GI,or biliary tract entered
e.g-Hernia repair
1.5% infection rate
Class II(clean/contaminated)
entrance into respiratory, GU,GI,or biliary tracts
e.g.-
Cholecytectomy,
elective bowel resection
? infection rate
Class II(clean/contaminated)
Controlled entrance into respiratory, GU,GI,or biliary tracts
Cholecytectomy, elective bowel resection
7.5% infection rate
Class III(contaminated)
Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, Acute non-purulent inflammation
e.g.-
Appendectomy
? infection rate
Class III(contaminated)
Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, Acute non-purulent inflammation
Appendectomy
15% infection rate
Class IV (dirty)
Old trauma wounds; devitalized tissue; existing clinical infection, perforated viscera. e.g.-
Hartmann’s for diverticular perforation
? Infection rate
Class IV (dirty)
Old trauma wounds; devitalized tissue; existing clinical infection, perforated viscera.
Hartmann’s for diverticular perforation
40% infection
Extend of Incisional SSI
Superficial Surgical Site Infection
Deep Surgical Site Infection
Organ/Space Surgical Site Infection
Risk of Infection(Pathogenesis)
Bacterial dose Virulence
Impairedhost resistance
Transmission Cycle in OT
Infectious agentsbacteria,virus,etc.
Susceptible Hosts(clients, service providers,
commu. members, Ancillary staffs)
Reservoirspeople,water,air,
Instruments
Places of exitResp.,GU,GI
Modes of transmissionContact, droplet, airborne,
vehicle
Place of entrybroken skin, surgical site,
mucous membrane
SSI – Risk Factors Operation Factors
Duration of surgical scrub
Maintain body temp.
Skin antisepsis
Pre-operative shaving
Duration of operation
Antimicrobial prophylaxis
Operating room ventilation
Inadequate sterilization of instruments
Foreign material at surgical site
Surgical drains
Surgical technique
Poor hemostasisFailure to obliterate dead
space Tissue trauma
Opportunity to Prevent SSI
An estimated 40%–60% of SSIs are preventable.
Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25%–50% of operations.
Four main strategies:
Prevent infection, diagnose and treat infection use antimicrobials wisely, and prevent transmission.
Antimicrobial prophylaxis
Def.: Surgical antimicrobial prophylaxis (AMP) refers to a brief course of an antimicrobial agent just before an operation begins.
AMP is not an attempt to sterilize tissues, but a critically timed use to reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses.
AMP does not pertain to prevention of SSI caused by postoperative contamination.
Intravenous infusion is the mode of AMP delivery in modern surgical practice.
Essentially all confirmed AMP indications pertain to elective operations in which skin incisions are closed in the operating room.
Antimicrobial prophylaxisFour principles to maximize the benefits of AMP:
Use an AMP agent for all operations or classes of operations in which its use has been shown to reduce SSI rates or for those operations after which incisional or organ/space SSI would represent a catastrophe.
Use an AMP agent that is safe, inexpensive, and bactericidal that covers the most probable intraoperative contaminants for the operation.
Time the infusion of the initial dose of antimicrobial agent so that a bactericidal concentration is established in serum and tissues by the time of skin incised.
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.
SSI – Wound/Surgery Classification
• Class 1 = Clean• Class 2 = Clean contaminated• Class 3 = Contaminated• Class 4 = Dirty infected
.
Prophylactic antibiotics indicated
Therapeutic antibiotics
AMP indications for clean operations
Two well-recognized indications for such clean operations are:
(1) when any intravascular prosthetic material or a prosthetic joint will be inserted, and
(2) for any operation in which an incisional or organ/space SSI would pose catastrophic risk. Examples are all cardiac operations, including cardiac pacemaker placement, vascular operations involving prosthetic arterial graft placement at any site or the revascularization of the lower extremity, and most neurosurgical operations
Some have advocated use of AMP during all operations on the Breast.