ali 200413basic concept of surgical site infection (ssi).pdf
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BASIC CONCEPT OF SURGICAL SITE INFECTION (SSI) Ali Sungkar Divisi Fetomaternal,Departemen Obstetri dan Ginekologi FKUI/RSUPN - CM
Criteria for defining SSIs
1999. Infect Control Hosp Epidemiol 1999;20:247-280.
} Superficial incisional } (skin or subcutaneous tissue) } Infection ≤30 days after procedure and at least 1 of
the following: – Purulent drainage from superficial lesion/organisms
isolated aseptically
– At least 1: pain/tenderness, swelling, redness, heat
– Superficial incision deliberately opened by surgeon unless culture negative
} or SSI diagnosed by surgeon or attending physician
Defining Surgical Site Infections
Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press.
All rights reserved.
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Deep incisional (deep soft tissue at incision site)
• Infection ≤30 days after procedure (no implant) or ≤1 year (with implant) plus at least 1 of of the following: – Purulent drainage from deep in incision but not
from organ/space – Spontaneous dehiscence or surgical opening of
deep incision with fever, pain, or tenderness – Abscess or other evidence of infection involving
deep incision
• or SSI diagnosed by surgeon or attending physician
Defining Surgical Site Infections (cont.)
Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of
Chicago Press. All rights reserved.
Organ/space (any site other than incision)
• Infection ≤30 days after procedure (no implant) or ≤1 year (with implant) plus at least 1 of the following: – Purulent drainage from a drain placed through a
stab wound into organ/space – Organisms isolated from a culture of fluid or
tissue – Abscess or other evidence of infection involving
the organ/space found by histopathologic examination, X-ray, or reoperation
• or SSI diagnosed by surgeon or attending physician
Defining Surgical Site Infections (cont)
Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press. All
rights reserved.
Class 1 – Clean ü Uninfected operative wound, no inflammation
Class II – Clean-Contaminated ü Alimentary tract (and others), under controlled
conditions without unusual contamination
Class III – Contaminated ü Major breaks in sterile technique, eg, gross
spillage from the gastrointestinal tract ü Incisions encountering acute inflammation
Class IV – Dirty-Infected ü Old traumatic wounds with dead tissue, infection,
perforated viscera
Surgical Wound Classification
Mangram AJ et al. Am J Infect Control. 1999;27:97–134.
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National Nosocomial Infections Surveillance System (NNIS)
Classification Wound Class SSI Risk
Clean 0 Lower
Higher
Clean-contaminated: GI/GU tracts entered in a controlled manner
1
Contaminated: open, fresh, traumatic wounds infected urine, bile gross spillage from GI tract
2
Dirty-infected:
3
n Increasing proportion of SSIs: à Antimicrobial-resistant
pathogens, MRSA……
n Unusual pathogens à Rhizopus oryzae à Clostridium perfringens à Rhodococcus bronchialis à Nocardia farcinica à Legionella pneumophila and
Legionella dumoffii à Pseudomonas multivorans
Microbiology
From Weiss CA, Statz CI, Dahms RA, et al: Six years of surgical wound surveillance at a tertiary care center. Arch Surg 134:1041,
Wound classification Patient factors Environmental factor
Clean Diabetes Preoperative antiseptic showering
Clean-contaminated
Obesity Preoperative hair removal
Contaminated Nicotine use Patient skin preparation
Dirty Steroid use Preoperative hand/forearm antisepsis
Malnutrition Antimicrobial prophylaxis Hospital stay h
Nares colonization with S. aureus Transfusion
Risk and prevention
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The inanimate environment is a reservoir of pathogens
~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X represents a positive Enterococcus culture
The pathogens are ubiquitous
Agent Mechanism of action
Gram positive bacteria
Gram negative bacteria
Rapidity of action
Residual activity
Alcohol Denature proteins
Excellent Excellent Most rapid Non
Chlorhexidine Disrupt cell wall
Excellent Good Intermediate Excellent
Iodine/ Iodophors by free iodine
Oxidation/ substitution
Excellent Good Intermediate Minimal
PCMX Disrupt cell wall
Good Fair Intermediate Good
Triclosan Disrupt cell wall
Good Good Intermediate Excellent
Mechanism and Spectrum of Activity for Commonly Used Antiseptics
Active Agents PI CHG CHG + Alc
Broad Spectrum X X X
Rapid Activity X
Residual Activity X X
Activity in Blood/Organic X X
Non-Irritating X X X
Toxic/Minimal Absorption X X X
PI = povidone iodine CHG = chlorhexidine gluconate Alc = alcohol (70%)
Perioperative Skin Preparation: A Comparison
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n The risk of SSI can be conceptualized :
n Dose of bacterial contamination x virulence Resistance of the
host patient = Risk of surgical site infection
n Surgical site: >105 microorganisms/gram of tissue
n Endotoxin: gram-negative bacteria
g stimulates cytokine production
g systemic inflammatory response syndrome
n Exotoxin: certain strains of clostridia & streptococci
g disrupt cell membranes
Pathogenesis
n Most common source: endogenous flora of the patient’s skin, mucous membranes, or hollow viscera.
g Staphylococcus aureus g Coagulase negative staphylococci n Gastrointestinal organ: g E.coli g Enterococci g Bacillus fragilis n Exogenous sources: g Surgical personnel or Operating room environment g Flora: Staphylococci and streprococci n Fungi: rarely cause SSIs
Pathogenesis
Sabiston Textbook of Surgery, 18th ed.
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Endogenous: patient’s skin or mucosal flora • Increased risk with devitalized tissue, fluid collection,
edema, larger inocula
Exogenous • Includes OR environment/instruments, OR air, personnel
Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection
• May occur days to weeks following the procedure Most infections occur due to organisms implanted during the procedure
Sources of SSIs
Surgical infection prevention
• SSI rates • Appropriate prophylactic antibiotic chosen • Antibiotic given within 1 hour before
incision • Discontinuation of antibiotic within 24
hours of surgery • Glucose control • Proper hair removal • Normothermia in colorectal surgery
patients
Performance Measures
n Diabetes g Controversial g Patients underwent CABG @ Increasing levels of HbA1c and SSI rates @ Increased glucose levels (>200 mg/dL)
n Nicotine use g Delays primary wound healing g Increase the risk of SSI
n Steroid use g Controversial
Patient characteristics
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n Malnutrition g Theoretical arguments: increase the SSI risk g Two randomized clinical trials: preoperative “nutritional therapy” did not reduce incisional and organ/space SSI risk.
n Prolonged preoperative hospital stay n Preoperative nares colonization with S. aureus
g Mupirocin ointment: Controversial n Perioperative transfusion
g No scientific basis
Patient characteristics
• Preoperative antiseptic showering • Preoperative hair removal • Patient skin preparation in the operating
room • Preoperative hand/forearm antisepsis • Antimicrobial prophylaxis
Operative characteristics : Preoperative issues
n Preoperative antiseptic showering g Decreases skin microbial colony counts g No evidance of benefit to reduce SSI rates
n Preoperative hair removal g Shaving: @ immediately before the operation: SSI rates 3.1% @ shaving within 24 hours preoperatively: 7.1% @ having performed >24 hours: SSI rate > 20%. g Depilatories: @ lower SSI risk than shaving or clipping @ hypersensitivity reactions
Operative characteristics : Preoperative issues
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n Patient skin preparation in the operating room g Most common used: Alcohol solutions Chlorhexidine gluconate Iodophors
n Preoperative hand/forearm antisepsis
Operative characteristics : Preoperative issues
1999. Infect Control Hosp Epidemiol 1999;20:247-280.
} Operating room environment g Ventilation
@ Positive pressure with respect to corridors and adjacent areas
g Environmental surfaces @ Rarely implicated as the sources of pathogens important in the development of SSIs. @ Important to perform routine cleaning of these surfaces g Conventional sterilization of surgical instruments @ Inadequate sterilization of surgical instruments has resulted in SSI outbreaks
Operative characteristics : Intraoperative issues
} Surgical attire and drapes g The use of barriers: @ Patient: minimize exposure to the skin, mucous membranes, or hair of surgical team members @ surgical team members: protect from exposure to blood and bloodborne pathogens.
} Asepsis and surgical technique g Rigorous adherence to the principles of asepsis by all
scrubbed personnel g Excellent surgical technique: reduce the risk of SSI. g Drains: increase incisional SSI risk.
Operative characteristics : Intraoperative issues
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} Incision care à The type of postoperative incision care @ Closed primarily: the incision is usually covered with a sterile dressing for 24 to 48 hours. @ Left open to be closed later: the incision is
packed with a sterile dressing. @ Left open to heal by second intention: packed
with sterile moist gauze and covered with a sterile dressing.
Operative characteristics : Postoperative issues
Treatment surgical site infection g Efflux of purulent material and pus g Fascia is intact: debridement Irrigated with N/S and packed to its base with saline-‐moistened gauze g Fascia separated: drainage or reoperation Most SSIs: healing by secondary intention
Operative characteristics : Postoperative issues
} Discharge planning
g The intent of discharge planning:
@ maintain integrity of the healing incision,
@ educate the patient about the signs and symptoms
of infection,
@ advise the patient about whom to contact to report
any problems.
Operative characteristics : Intraoperative issues
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1. SSI risk stratification 2. SSI surveillance methods
a. Inpatient SSI surveillance b. Postdischarge SSI surveillance
SSI Surveillance
} SENIC risk index: 1) An abdominal operation, 2) An operation lasting >2 hours, 3) A surgical site with a wound classification of
either contaminated or dirty/infected 4) An operation performed on a patient having
>3 discharge diagnoses.
SSI risk stratification
The inanimate environment is a reservoir of pathogens
~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE
(+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
X represents a positive Enterococcus culture
The pathogens are ubiquitous
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Inpatient SSI surveillance (1) Direct observation of the surgical site:
g surgeon, g trained nurse surveyor, g Infection control personnel
the most accurate method to detect SSIs
(2) Indirect detection: g review of laboratory reports, g Patient records, g discussions with primary care providers
SSI surveillance methods
• Patient questionnaires • Surgeon questionnaires • Nurse observation of the wounds at
patient’s home or during a routine postoperative visit
Postdischarge SSI surveillance
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Resources for Implementation WHO Surgical Safety Checklist
World Health Organization. Safe Surgery Saves Lives http://www.who.int/patientsafety/safesurgery/en/ Accessed 19 Nov 2009
q Criteria for defining SSIs q Surgical wound classification q SSI risk factor:
o Patient factor o Operative factors o Surgical wound classification
q Antimicrobial prophylaxis q Treatment surgical site infection q SSI surveillance methods
Take Home Message
Terima Kasih