1. Surgical Site Infections

2. Ignaz Semmelweis
1847
Realized that washing hand with a chlorinated lime solution decreased incidence of newborn death from “puerperal fever’.

3. Joseph Lister 1883-1897 British surgeon
Used Carbolic Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.

4. Outline : Important Terms Antiseptics Surgical wounds
Post-operative Infections
Surgical Site Infection
Hospital Acquired Infections
Antibiotic Prophylaxis

5. Definition : Colonization
Bacteria present in a wound with no signs or symptoms of systemic inflammation
Usually less than 105 CFU/mL

6. Contamination Transient exposure of a wound to bacteria
Varying concentrations of bacteria possible
Time of exposure suggested to be < 6 hours

7. DECONTAMINATION:
is the process of removing or neutralizing infectious or injurious m.o. from inanimate objects
CLEANING:
physically removes ALL visible blood, body fluid, or other foreign material as dust or soil from skin or intimate objects.

8. ASEPSIS/ASEPTIC TECH.:
is the practices performed just before or during clinical or surgical procedure to reduce the risk of infection that produce a state of asepsis .
ANTISEPSIS: is the prevention of infection by killing or inhibiting the growth of m.o. on skin or body tissues.

9. DISINFECTION:
is the elimination of most (but not all) disease causing m.o. from inanimate objects .
High level disinfection –by boiling or chemicals- eliminate ALL m.o. except some bacterial endospores.

10. STERILIZATION:
is the process that remove ALL m.o. including bacterial endospores form inanimate objects

11. antiseptics Antiseptics: Kill m.o. on skin
Not strong enough to use on instruments
For surgical scrubs; preparations of pt. skin or mm before clinical procedures
DO NOT use for processing or storage of instruments
Disinfectants:
Kill m.o. on surfaces (counters; exam tables; floors…etc.)
DO NOT use on skin , may irritate skin
Acceptable antiseptics:
As ( Alcohol; Chlorhexidine; Iodine preparations; Iodophor; Triclosan)

12. Alcohol (60%-90% ethyl or isopropyl alcohol)
Advantage:
Rapidly kill ALL fungi ; G+ve; G-ve; mycobacteria; Viruses (HBV,HIV) à ethyl alcohol kill ALL viruses
Retard regrowth of organisms even under gloves for several hours
Are relatively inexpensive

13. evaporate rapidly and cause skin dryness
Disadvantage:
evaporate rapidly and cause skin dryness
Not appropriate for vaginal preparation
Can be inactivated by organic materials
Flammable
Do not penetrate organic material
None action on endospores
Not for use on mm ; not good for physical cleaning of skin

14. Chlorhexidine (2%-4%) (Hibitane; Hibiscrub)
4% is the recommended concentration of chlorhexidine gluconate (CHG)
Either as pure CHG or 0.5% CHG in 60%-90% alcohol
Advantage:
Has persistent action on skin; stays chemically active for at least 6 hours
Repeated use increase the no. of inhibited mo
Minimally affected by organic material

15. None action against endospores; fair action on fungi and TB
Disadvantage:
Expensive , and not always present
Action reduced or neutralized by natural soap or hard tap water
Must be used repeatedly for maximum effective and residual activity
Can cause dermatitis when used frequently for hand washing
Aqueous preparation is prone to contamination
None action against endospores; fair action on fungi and TB

16. Iodine and iodophor solutions
2 types:
1-3% aqueous solution à Lugol
70% alcoholic tincture
Iodophor are solutions of iodine mixed with carrier that release small amount of iodine
The most common iodophor is Betadine
Iodophor require up to 2 min. of contact time to release free iodine

17. Advantage: Inexpensive; effective and commonly available
Iodophor are non-irritating to skin and mm making them ideal for vaginal preparation before IUD insertion
Does not stain skin at 1:2500 concentration

18. Disadvantage:
Little residual effect (30-60 minutes)
Inactivated by organic materials
Iodine à skin irritation ( need alcohol for removing it) .
May cause hypothyroidisms in neonates due to skin absorption
Iodine not iodophor is the only antiseptic effective against endospores

19. Surgical Wound Classification
Clean
Clean contaminated
Contaminated
Dirty

20. Class I Wound (Clean) Atraumatic wound without inflammation
Do not enter GI, GU, biliary, or respiratory tract
1.5% infection rate
Class I wounds are the simple surgeries without violation of the hollow visceral structures in a non inflamed, atraumatic wound. These wounds rarely become infected. One example would be an inguinal hernia repair.

21. Class II Wound (Clean-Contaminated)
Respiratory, GI, GU, or biliary tract entered under controlled conditions
5% infection rate expected
Class II wounds involve controlled entry into a hollow visceral structure. Examples would be cholecystectomy and elective colon resections. A higher incidence of infection is expected.

22. Class III Wounds (Contaminated)
Traumatic wounds
Breaks in sterile technique
Gross spillage from GI tract
Acute, nonpurulent inflammation
10% anticipated infection rate
Class III wounds include major breaks in sterile technique, trauma, gross spillage of GI contents and acute nonpurulent inflammation, such as from a nonperforated acute appendicitis.

23. Class IV Wounds (Dirty)
Old traumatic wounds
Devitalized tissue
Clinical infection present
Perforated viscus
40% expected infection rate
Class IV wounds involve older trauma, devitalized tissues, infection present at time of the operation or perforated hollow viscus. Thus, perforated acute appendicitis has a much higher wound complication rate than nonperforated.

24. SSI – Wound Classification
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Prophylactic antibiotics indicated
Therapeutic antibiotics
Surgical site infections are categorized into four classes depending on wound type. Class 1 is a clean wound, class 2 is a clean contaminated wound, class 3 is a contaminated wound, and class 4 is a dirty infected wound.
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

25. Infection Infection is defined by:
Microorganisms in host tissue or the bloodstream
Inflammatory response to their presence.

26. Inflammatory Response
Localized:
Rubor, Calor, Dolor, Tumor, and functio laesa (loss of function)
Systemic:
Systemic Inflammatory Response Syndrome (SIRS)

27. S.I.R.S. Any Two of the Following Criteria
Temperature: < 36.0, >38.0
Heart Rate : >90
Respiratory Rate: >20
WBC: <4,000, >12,000

28. Sepsis
Definition: SIRS plus evidence of local or systemic infection.
Septic Shock
Definition: Sepsis plus end organ hypoprofusion. Mortality of up to 40%

30. Soft Tissue Infections:
Cellulitis
Abscess
Necrotizing Infections

31. Cellulitis

32. Cellulitis
Definition: Diffuse infection with severe inflammation of dermal and subcutaneous layers of the skin
Diagnosis: Pain, Warmth, Hyperesthesia
Treatment: Antibiotics.
Common Pathogens: Skin Flora (Streptococcus/Staphylococcus)

33. Abscess

34. Abscess
Definition: Infectious accumulation of purulent material (Neutrophils) in a closed cavity
Diagnosis: Fluctuant: Moveable and compressible
Treatment: Drainage

35. Necrotizing Soft Tissue Infection

36. Necrotizing Soft Tissue Infection
Definition: Deep infection of skin and soft tissue that may spread rapidly along facial planes.
Diagnosis: Purely Clinical, dishwater discharge, gray tissue, pain out of proportion to examination, bulla, and dark, golden discoloration.
Treatment: True Surgical Emergency, Antibiotics

37. Necrotizing Soft Tissue Infection
Common Pathogens
Clostridium
Group A streptococcus
Polymicrobial

38. Post-Operative Infections
Fever After Surgery
The “Five W’s”
Wind: Atelectisis
Water: UTI
Walking: DVT
Wonder Drug: Medication Induced
Wound: Surgical Site Infection

39. Surgical Site Infection(SSI) :
Infection at or near the site of surgery that occurs within 30 days of surgery if there is no implant (hardware, artificial graft, mesh, etc) OR occurs within 3 months of the surgery with an implant in place
From CDC’s NNIS

40. Patients that develop SSI have twice the mortality and are:
Why Prevent SSIs?
Approximately 500,000 surgical site infections (SSI) occur annually in the United States
Patients that develop SSI have twice the mortality and are:
60% more likely to spend time in ICU
5 times more likely to be readmitted

41. Surgical Site Infections
3rd most common hospital infection
Incisional
Superficial
Deep
Organ Space
Generalized (peritonitis)
Abscess

42. Cross Section of Abdominal Wall Depicting CDC SSI Classifications

43. Superficial Incisional SSI
Infection occurs within 30 days after the operation and involves only skin or subcutaneous tissue of the incision
Superficial incisional SSI
Skin
Subcutaneous tissue
The first type of surgical site infection is the superficial incisional surgical infection which occurs within 30 days post-op and involves only the skin or subcutaneous tissue.
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

44. Deep Incisional SSI
Infection occurs within 30 days after the operation if no implant is left in place or within 3 months if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue (e.g., fascia and muscle layers)
Deep incisional SSI
Superficial incisional SSI
A more serious SSI is a deep incisional surgical infection, which extends past the superficial layer. The infection occurs within 30 days post-op only if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operation and the infection involves the deep soft tissue, which include the fascia and muscle layers.
Deep soft tissue (fascia & muscle)
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

45. Organ/Space SSI
Infection occurs within 30 days after the operation if no implant is left in place or within 3months if implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation
Superficial incisional SSI
Deep incisional SSI
The most extensive of these surgical infections involves the organs and the space surrounding the organs. These infections can occur within 30 days post-op if no implant is left in place or within 1 year if an implant is in place and the infection appears to be related to the operation and the infection involves any part of the anatomy, other than the incision, which was opened or manipulated during the operation.
Organ/space SSI
Organ/space
Mangram AJ et al. Infect Control Hosp Epidemiol ;20:

47. Risk factors
endogenous contamination (for example, procedures that involve parts of the body with a high concentration of normal flora such as the bowel)
exogenous contamination (for example, prolonged operations that increase the length of time that tissues are exposed)

48. diminish the  general immune response (for example, diabetes, malnutrition, or immunosuppressive therapy with radiotherapy, chemotherapy or steroids) or local immune response (for example, foreign bodies, damaged tissue or formation of a haematoma).

49. Host Risk Factors Diabetes mellitus Hypoxemia Hypothermia Leukopenia
Nicotine (tobacco smoking)
Immunosuppression
Malnutrition
Poor skin hygiene

50. Perioperative Risk Factors
Operative site shaving
Breaks in operative sterile technique
Improper antimicrobial prophylaxis
Prolonged hypotension
Contaminated operating room
Poor wound care postoperatively
Hyperglycemia
Wound closure technique

51. Operative Antibiotic Prophylaxis
Decreases bacterial counts at surgical site
Given within 30 minutes prior to starting surgery
Vancomycin 1-2 hours prior to surgery
Redose for longer surgery
Do not continue beyond 24 hours

52. Principles of Antibiotic Prophylaxis
Preop administration, serum levels adequate throughout procedure with a drug active against expected microorganisms.
High Serum Levels
Preop timing
IV route
Highest dose of drug
During Procedure
Long half-life
Long procedure–redose
Large blood loss–redose
Duration
None after wound closed
24 hours maximum
Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:

54. Treatment
Incisional: open surgical wound, antibiotics for cellulitis or sepsis
Deep/Organ space: Source control, antibiotics for sepsis

55. Use/Choice of Antibiotics
Use only when indicated
Start with broad spectrum antibiotics designed to cover likely pathogens
Take cultures when possible
Deescalate spectrum once pathogen is know
Have a plan for duration

56. Thank You