Surgical Site Infections

SSIs
ØSurgical site infections (SSIs) are infections of
the tissues, organs, or spaces exposed by
surgeons during performance of an invasive
procedure.
Øaccounts for
ü about 15% of all health-care associated
infections.
ü about 37% of the hospital-acquired
infections of surgical patients.
§ Infected patients are twice as likely to die, twice
as likely to spend time in an intensive care unit
and five times more likely to be readmitted after
discharge.
§ By definition, they can occur anytime from 0 to
30 days after the operation or up to 1 year after
a procedure that has involved the implantation
of a foreign material.
Etiology
§ The microbiology of SSI is related to the
bacterial flora present in the exposed
anatomic area after a particular procedure.
§ S. aureus remains the most common
pathogen in SSIs, followed by coagulase-
negative staphylococci, enterococci,
and E.coli.
Common bacteria causing surgical
infection
ØStreptococci(Gram positive)
R ß-haemolytic Streptococcus,
• Resides in the pharynx of 5–10% of the
population.
• It is the group A Streptococcus also called
Streptococcus pyogenes
• release enzymes such as streptolysin,
streptokinase and streptodornase.
RStreptococcus faecalis
• Is an enterococcus in Lancefield group D
ØBoth Streptococcus pyogenes and
Streptococcus faecalis may be involved in
wound infection after large bowel surgery.
ØAll the streptococci remain sensitive to
penicillin and erythromycin.
ØThe cephalosporins are a suitable
alternative in patients who are allergic to
penicillin.
ØStaphylococci Gram positive
RStaphylococcus aureus
• is found in the nasopharynx of up to 15%
of the population.
• Some strains are resistant to many
common antibiotics (especially methicillin
resistant Staphylococcus aureus, MRSA)
• MRSA can be found in the nose of
asymptomatic carriers amongst both
patients and hospital workers
Clostridia gram-positive
RClostridium per-fringens is the cause of
gas gangrene, and C. tetani causes
tetanus after implantation into tissues or
a wound.
RC l o s t r i d i u m d i f f i c i l e i s t h e c a u s e o f
pseudomembranous colitis.
Aerobic gram-negative bacilli
• these bacilli are normal inhabitants of the
large bowel.
• Escherichia coli and Klebsiella spp. are
lactose fermenting; Proteus is non-lactose
fermenting.
• M o st o rgan ism s in t h i s g r o u p a c t i n
synergy with Bacteroides to cause SSIs
after bowel operations (in particular,
appendicitis, diverticulitis and peritonitis).
§ Escherichia coli is a major cause of
urinary tract infection.
§ Pseudomonas spp. tend to colonise burns
and tracheostomy wounds, as well as the
urinary tract.
§ Bacteroides
§ Bacteroides are non-spore-bearing, strict
anaerobes that colonise the large bowel,
vagina and oropharynx.
§Bacteroides fragilis is the principal
organism that acts in synergy with aerobic
gram-negative bacilli to cause SSIs,
including intra-abdominal abscesses after
colorectal or gynecological surgery
§ They are sensitive to the imidazole's (e.g.
metronidazole) and some cephalosporins
(e.g. cefotaxime)
§ Endogenous: present in or on the host
§ Exogenous: acquired from OR/ward
The development of SSIs is related to three factors:
(a) The degree of microbial contamination of the
wound during surgery.
(b) The duration of the procedure.
(c) Host factors
Factors that determine whether a wound will
become infected
§ Host response
§ Virulence of infective agent
§ Vascularity and health of tissue being invaded
§ Presence of dead or foreign tissue
§ Presence of antibiotics during the ‘decisive
period’
Methods of scoring infection
§ Several different scoring systems have been
described that objectively evaluate wound status
or risk of infection.
PASEPSIS
PSouthampton wound grading
PS E N I C The risk ind e x i n t h e S t ud y o n t h e
Efficacy of Nosocomial Infection Control.
PNNIS risk index
§ The ASEPSIS (Additional treatment, Serous
discharge, Erythema, Purulent exudates,
Separation of deep tissues, Isolation of bacteria
and Stay duration as inpatient)
§ This scale can be used to monitor and record the
rate and severity of surgical site infections.
§ ASEPSIS scores range from 0 to 70, with
the following interpretation:
0–10, satisfactory healing;
11–20, disturbance of healing;
 21–30, minor wound infection;
31– 40; moderate wound infection;
> 40, severe wound infection
 Types of SSIs

ØSSIs
üIncisional(superficial
and deep)
üo r g a n / s p a c e
infections
Incisional (superficial)
ØInfection - within 30 days
Ø involves - only skin or subcutaneous tissue
AND
at least one of the following:
§ Purulent drainage.
§ positive wound culture
§ pain, tenderness, localized swelling, redness.
§ diagnosis by a surgeon.
Incisional (deep)
ØInfection
-within 30 days if no implant is left in place
-within 1 year of surgery - implant is left in place.
Ø involves - soft tissue (muscle and fascia layers)
AND
at least one of the following:
§ Purulent drainage.
§ wound dehiscence
§ fever (> 38 °C)
§ an abscess or other evidence of infection by
histopathology or imaging study
Organ–space surgical site infection
Ø Infection - within 30 days if no implant is left in place
-within 1 year of surgery if an implant is left in place.
Ø involves - any part of the anatomy other than the incision
that is opened or manipulated during an operation.
AND
at least one of the following:
§ Purulent drainage.
§ positive wound culture
§ an abscess or other evidence of infection by histopathology
or imaging study
Major SSI
§ a wound with
significant quantities
of pus.
§ needs a secondary
procedure to drain.
§ systemic signs may
present( tachycardia,
pyrexia and a raised
white cell count).
Minor SSI
§ wound with pus or
infected serous fluid
§ no systemic signs or
delay in return home.
Prevention And Treatment Of SSIs
§ Important principles in prophylaxis can be
grouped into factors pertaining to:
üskin preparation.
üantimicrobial therapy.
üpatient physiological management.
Patient Skin Preparation

ØIt is the removal of as many microorganisms as

possible from the operative site and
surrounding areas before operation.
ØIts done by
üTrimming
üMechanical washing
üChemical disinfection
Ø The purpose of skin preparation is to render the surgical

site as free as possible from transient and resident

microorganisms, dirt, and skin oil .

Ø should begin the night before a planned surgical procedure

with a full body bath or shower using soap or an antiseptic

agent.

Ø The perioperative nurse should assess the patient’s skin

before, during, and after the prepping process.

Ø Documentation of the condition of the patient’s skin with

The Trim Preparation
Hair
ü supports the growth of microorganisms.
ü interfere with exposure, closure, or the surgical site dressing.
ü prevent adequate skin contact with patient return electrodes
or ECG.
Ø The skin at and around the incision site is trimmed
immediately prior to surgery.
Ø Hair removal from an operative site should be performed in
the operating room with clippers rather than with a razor,
to avoid creating nicks in the skin that could foster
bacterial growth.
Surgical scrub
§The Surgical scrub is the process of
removing as many microorganisms as
possible from the hands and arms by
mechanical washing and chemical
antisepsis before participating in a surgical
procedure.
§ Skin is never rendered sterile.
§ Mechanical - this process removes soil and
transient organisms with friction.
§ Chemical - this process reduces resident flora and
inactivates microorganisms with an antimicrobial
or antiseptic agent.
Purpose of Surgical Scrub

Ø To decrease the number of resident

microorganisms on skin to an irreducible

minimum

ØT o k e e p t h e p o p u l a t i o n o f m i c r o o r g a n i s m s

minimal during the surgical procedure by

suppression of growth

ØTo reduce the hazard of microbial contamination of

the surgical wound by skin flora

Scrub Sink

§ Adequate scrubbing and handwashing

facilities should be provided for all

operating team members.

§ The scrub room is adjacent to the OR

for safety and convenience.

§ The sink should be deep and wide

enough to prevent splash.

§ Scrub sinks should be used only for

scrubbing or handwashing
§ They should not be used to clean or rinse
contaminated instruments or equipment.
Equipment
ü Soft brush or disposable sponges
ü Soap or detergent
ü Running water
The desirable characteristics of antimicrobial
agents are as follows:
§ Broad spectrum

§ Fast acting and effective

§ Nonirritating and non-sensitizing

§Prolonged action (i.e., leaves an

antimicrobial residue on the skin to

temporarily prevent growth of
microorganisms)
Antimicrobial scrub agents

§ Chlorhexidine Gluconate

§ Iodophors

§ Alcohol

§ Hexachlorophene
Preparation for the Surgical Scrub

§ The skin and nails should be kept clean and in

good condition.

§ Finger nails should not reach beyond the fingertip.

§ Fingernail polishing should be avoided.

§ All Jewelry should be removed from the fingers

and wrists.
Methods of Scrubbing
üThe counted brush-stroke method
üThe timed scrub method
Drying the Hands and Arms
§ The sterile gown is put on immediately after the surgical

scrub.

§ The sterile gloves are donned immediately after gowning.

Gowning

§ The purpose of wearing sterile gown is in order to provide

sterile field.

There are two methods of sterile gowning:-

ü Gowning self and

ü Gowning another
§ The scrub person gowns and gloves from a
surface separate from the main sterile field using
the closed-gloving method
§ and then gowns and gloves the surgeon and the
rest of the sterile team using the open-assisted or
closed-assisted gloving method.
The Scrub Preparation
ØA f t e r t h e p a t i e n t i s a n e s t h e t i z e d a n d / o r
positioned on the operating bed, The skin at and
around the incision site is cleansed with
antiseptic agent immediately before draping.
ØAgents such as iodine, iodophors, alcohol can be
used.
The ideal antiseptic skin cleansing agent should have the
following qualities:
§ It has broad-spectrum antimicrobial action and rapidly
decreases the microbial count. It should be virucidal and
active against protozoa and yeasts.
§ It can be quickly applied and remains effective against
microorganisms.
§ It can be safely used without skin irritation or
sensitization. It should be nontoxic.
§ It effectively remains active in the presence of alcohol,
organic matter, soap, and detergent.
§ It should be nonflammable when dried for use with laser,
electrosurgical, and other high-energy devices.
 Skin preparation for Specific Anatomic Areas

Eye
§ Never shave/trim the eyebrows; the eyelashes may
be trimmed.
§ Use soft cotton balls.
§ Irrigate from the inner to the outer canthus.
§ Use nonirritating antiseptic agents.
§ The conjunctival sac is flushed with nontoxic agent
(normal saline)
§ The ear on the affected side should be plugged with
cotton.
Ear
§ Clean folds with cotton tipped applicators.
§ Prevent pooling of solution in the ear canal.

Face
üHas several unclean areas (the mouth, nose, and
hairline)
üDifficult to avoid contaminating the prep when
the usual technique is employed.
üPrep from the center outwards (from hairline)
üReturn to the incision site using clean sponges
and prep that area last.
üBraid, cap or held back the hair with clips prior
to the prep.
Flat surfaces - abdomen
PFollow the prep guidelines.
PUse cotton tip applicators to remove dead skin
from the umbilicus.
PIf colostomy is present place a soapy sponge over it.
Prep the colostomy last.
Elevated limb
üPlace a moisture-proof pad on the operating bed
under the elevated extremity to protect the
operating bed.
üElevate and support the extremity until sterile
drapes are applied.
üBegin the prep at the most elevated point, rather
than at the incision site.
Vagina
üBegin a few centimeters from the vulva.

ü Extend the prep outwards to include the thighs and

lower abdomen.

üSponge sticks are used to prep the vagina itself.

üTo complete the prep wash the vulva and anus and
passing the soapy sponge downward.

üDiscard the sponge after it passes the anus.

üRepeat several times, always starting with a new sponge.

Anus

P Is considered a contaminated area.

P Prep the surrounding area first and the anus itself last.

Documentation

P Details of the preoperative skin condition and preparation.

P should be documented in the patient’s intra operative

record.
Drapes and Draping
 Drapes are pieces of cloth used to cover areas in

order to provide sterile field.

 Draping is the procedure of covering the patient

and surrounding areas with a sterile barrier to

create and maintain an adequate sterile field.
Towels
PThese are usually the basic items in every draping routine.
PFour towels are placed around the immediate surgical site;
this is called “squaring off” the site.
P Four towel clips secure the towels.
Plain Sheet
PThis is also called a minor sheet, top sheet, or
bottom sheet.
PIt is a large rectangular sheet that may be placed
directly above or below the incisional area.
P It is used in various ways in the draping routine,
according to its size.
Plastic Drape
§ This is a commercially prepared item.
§ Two or three people are needed to place the drape
§ The sheet is made of thin plastic that is adherent on one side
§ Some surgeons feel that this type of barrier causes a greater
proliferation of bacteria.
§ Place drapes on a dry area.

§ Allow sufficient time to permit careful application.

§ Allow sufficient space to observe sterile technique.

§ Handle drapes as little as possible.

§ Never reach across the OR bed to drape the

opposite side; go around it

§ Never flourish drapes.

§ If a drape becomes contaminated or has a hole in it, discard
it.
§ Never allow gloved hands to come into contact with the
patient’s prepared skin during the draping process.
§ Whenever draping, always provide a cuff for the gloved
hand.
§ Never allow a drape to extend outside the sterile area,
unless it is to remain there.
§ Do not allow the drapes to touch the floor or become
tangled in floor equipment.
§ The drape must not be adjusted once it is placed
 Preoperative antimicrobial
therapy
§ in the vast majority of cases only a single dose of
antibiotic is required, and only for certain types of
procedures.
Antibiotic prophylaxis
§ Not required in clean surgery unless a
prosthesis is implanted.
§ Use antibiotics that are effective against expected
pathogens within local hospital guidelines.
§ Plan for single-shot intravenous administration
at induction of anesthesia.
§ Repeat only during long operations or if there is
excessive blood loss
Patient Physiological Management
A Maintenance of euglycemia (serum glucose <200
mg/dL)
A Normothermia.
A Optimization of tissue oxygenation.
ACessation of smoking

both hypothermia and hypoxia during surgery are

associated with a higher rate of SSI.
Halsted's Principle of surgical technique
§ Gentle handling of tissue
§ Preservation of blood supply
§ Strict aseptic technique
§ Minimum tension
§ Accurate tissue apposition
§ Obliteration of dead space
§ Maintain hemostasis
Management of SSI
§ SSI is managed depending on the type of SSI—
superficial, deep or organ space.
§ All infected material and pus should be removed
from the wound site—debridement.
§ Sutures are removed to allow free drainage of
infected material.
§ Infected fluid is sent for culture and sensitivity
and suitable antibiotics are started.
§ Once wound shows signs of healing by healthy
granulation tissue, secondary suturing is done.