Ariandi Setiawan

SURGICAL SITE INFECTION

 2010 : 16 million operative procedures were

performed (US). Recent prevalence study : SSIs were the most common healthcare-associated infection, 31% of all HAIs among hospitalized patients. NHSN data : 2006-2008 (16,147 SSIs 849,659 procedures) showed an overall SSI rate of 1.9%.

 Advances have been made in infection

control practices; improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis SSIs remain a substantial cause of morbidity and an associated mortality rate of 3% has been attributed to them. Of this, 75% of the mortality rate has been directly related to the SSI.

 Surveillance of SSI w/ feedback of

appropriate data to surgeons - shown to be an important component of strategies to reduce SSI risk. A successful surveillance program includes the use of epidemiologically-sound infection definitions and effective surveillance methods, stratification of SSI rates according to risk factors associated with SSI development, and data feedback.

Definition

The Centers for Disease Control and Prevention (CDC) term for infections associated with surgical procedures was changed from surgical wound infection to surgical site infection in 1992 These infections are classified into incisional, organ, or other organs and spaces manipulated during an operation; incisional infections are further divided into superficial (skin and subcutaneous tissue) and deep (deep soft tissue-muscle and fascia)

These definitions should be followed universally for surveillance, prevention, and control of surgical site infections.

Operative Procedure
Procedure that is performed on a patient who

is an inpatient or an outpatient; and takes place during an operation (defined as a single trip to the operating room [OR] where a surgeon makes at least one incision through the skin or mucous membrane, including laparoscopic approach, and closes the incision primarily* before the patient leaves the OR)

ASA Score
Assessment by the anesthesiologist of the patients preoperative physical condition using the American Society of Anesthesiologists (ASA) Classification of Physical Status
1. Normally healthy patient 2. Patient with mild systemic disease 3. Patient with severe systemic disease that is not incapacitating 4. Patient with an incapacitating systemic disease that is a constant threat to life 5. Moribund patient (< 24hr)

Surgical Wound Classification

Class Iclean. Uninfected operative wound with no inflammation and in which the respiratory, gastrointestinal (GI), genital and urinary tracts were not entered. Clean wounds are closed at surgery and, if necessary, drained with closed drainage.
Class IIclean-contaminated. Wound in which the respiratory, GI, genital or urinary tract(s) were entered under controlled conditions but without unusual contamination or spillage of contents.

Surgical Wound Classification

Class IIIcontaminated. Open, fresh accidental wound or an operation with a major break(s) in aseptic technique (e.g., open cardiac massage) or gross spillage from the GI tract. Also included are incisions in which acute, nonpurulent inflammation is found.
Class IVdirty or infected. Old wounds with dead tissue and those that involve existing clinical infection or a perforated bowel, suggesting that the pathogens causing the postoperative infection were present in the wound before the surgery.

Superficial Incisional SSI

must meet one of the following criteria: Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and patient has at least one of the following:

purulent drainage from the superficial incision.

organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.

Superficial Incisional SSI

at least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon, and is culturepositive or not cultured. A culture-negative finding does not meet this criterion. diagnosis of superficial incisional SSI by the surgeon or attending physician

Deep Incisional SSI

must meet one of the following criteria: Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place

and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision
and patient has at least one of the following:

Deep Incisional SSI

purulent drainage from the deep incision but not from the organ/space component of the surgical site a deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture- positive or not cultured and the patient has at least one of the following signs or symptoms: fever (>38C), or localized pain or tenderness. A culture-negative finding does not meet this criterion. an abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination

diagnosis of a deep incisional SSI by a surgeon or attending physician

Organ / Space SSI

An organ/space SSI must meet one of the following criteria:

Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure And infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure

and

Organ / Space SSI

patient has at least one of the following:

purulent drainage from a drain that is placed through a stab wound into the organ/space

organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination

diagnosis of an organ/space SSI by a surgeon or attending physician.

Prevention

Preparation of the Patient

Ventilation Hand/forearm antisepsis for surgical team members

Management of infected or colonized surgical personnel

Antimicrobial Prophylaxis Surgical Attire and Drapes Preoperative Hand & Forearm Antisepsis

Preparation of the Patient

Identify and treat all infections remote to the surgical site before elective operation and postpone elective operations on patients with remote site infections until the infection has resolved. Category IA Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. Category IA

Preparation of the Patient

If hair is removed, remove immediately

before the operation, preferably with electric clippers. Category IA Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively. Category IB

Preparation of the Patient

Stopping use of tobacco products. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes or any other form of tobacco consumption (e.g., chewing/ dipping). Category IB Do not withhold necessary blood products from surgical patients as a means to prevent SSI. Category IB

Preparation of the Patient

Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day. Category IB Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. Category IB

Preparation of the Patient

Use an appropriate antiseptic agent for skin preparation (Table 6). Category IB Keep preoperative hospital stay as short as possible while allowing for adequate preoperative preparation of the patient. Category II

Ventilation
Maintain positive-pressure ventilation in the

operating room with respect to the corridors and adjacent areas. Category IB Maintain a minimum of 20 air changes per hour, of which at least 4 should be fresh air. Category IB Filter all air, recirculated and fresh, through the appropriate filters per the American Institute of Architects recommendations. Category IB

Ventilation
Introduce all air at the ceiling, and exhaust

near the floor. Category IB Do not use UV radiation in the operating room to prevent SSI. Category IB Keep operating room doors closed except as needed for passage of equipment, personnel and the patient. Category IB

Ventilation
Consider performing orthopedic implant

operations in operating rooms supplied with ultraclean air. Category II Limit the number of personnel entering the operating room to necessary personnel. Category II

Hand/forearm antisepsis for surgical team members

Keep nails short and do not wear artificial nails. Category IB Perform a preoperative surgical scrub for at least 2 to 5 minutes using an appropriate antiseptic. Scrub the hands and forearms up to the elbows. Category IB

Hand/forearm antisepsis for surgical team members

After performing the surgical scrub, keep

hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and put on a sterile gown and gloves. Category IB

Management of infected or colonized surgical personnel

Educate and encourage surgical personnel who have signs and symptoms of a transmissible infectious illness to report conditions promptly to their supervisory and occupational health service personnel. Category IB

Management of infected or colonized surgical personnel

Develop well-defined policies concerning patient care responsibilities when personnel have potentially transmissible infectious conditions. These policies should govern: (a) personnel responsibility in using the health service and reporting illness, (b) work restrictions, and (c) clearance to resume work after an illness that required work restriction. The policies also should identify persons who have the authority to remove personnel from duty. Category IB

Management of infected or colonized surgical personnel

Exclude from duty surgical personnel who have draining skin lesions until infection has been ruled out or personnel have received adequate therapy and infection has resolved. CategoryIB Do not routinely exclude surgical personnel who are colonized with organisms such as S. aureus (nose, hands or other body site) or group A Streptococcus, unless such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting. Category IB

Antimicrobial Prophylaxis
Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI for a specific operation and published recommendations. Category IA Do not routinely use vancomycin for antimicrobial prophylaxis. Category IB

Antimicrobial Prophylaxis
Administer by the intravenous route the

initial dose of prophylactic antimicrobial agent, timed such that a bactericidal concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room. Category IA

Antimicrobial Prophylaxis
Before elective colorectal operations in addition to above, mechanically prepare the colon by use of enemas and cathartic agents. Administer nonabsorbable oral antimicrobial agents in divided doses on the day before the operation. Category IA For high-risk cesarean section, administer the prophylactic antimicrobial agent immediately after the umbilical cord is clamped. Category IA

Surgical Attire and Drapes

Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way or if sterile instruments are exposed. Wear the mask throughout the operation. Category IB Wear a cap or hood to fully cover hair on the head and face when entering the operating room. Category IB Do not wear shoe covers for the prevention of SSI. Category IB

Surgical Attire and Drapes

Wear sterile gloves if a scrubbed surgical team member. Put on gloves after putting on a sterile gown. Category IB Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration). Category IB Change scrub suits that are visibly soiled, contaminated and/or penetrated by blood or other potentially infectious materials. Category IB

Asepsis and Surgical Technique

Adhere to principles of asepsis when placing intravascular devices, spinal or epidural anesthesia catheters, or when dispensing and administering intravenous drugs. Category IA Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris) and eradicate dead space at the surgical site. Category IB

Asepsis and Surgical Technique

Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be heavily contaminated (e.g., Class III and Class IV). Category IB If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible. Category IB

Postoperative Care
Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily. Category IB Wash hands before and after dressing changes and any contact with the surgical site. Category IB When an incision dressing must be changed, use sterile technique. Category II Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms. Category II

Data Analyses

Basic SSI Risk Index. The index used in NHSN assigns surgical patients into categories based on the presence of three major risk factors:
1. Operation lasting more than the duration cut point hours, where the duration cut point is the approximate 75th percentile of the duration of surgery in minutes for the operative procedure (1) 2. Contaminated (Class 3) or Dirty/infected (Class 4) wound class (1) 3. ASA classification of 3, 4, or 5 (1) sum of the number of these factors present at

the time of the operation

Data Analyses

The SSI rates per 100 operative procedures are calculated by dividing the number of SSIs by the number of specific operative procedures and multiplying the results by 100

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