surgical site infectionsprevention and care
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SURGICAL SITE INFECTIONS
PREVENTION AND CARE
Dr.T.V.Rao MD
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Surgical Site InfectionCDC defines
A surgical site infection is an infection
that occurs after surgery in the part of
the body where the surgery took place.Surgical site infections can sometimes be
superficial infections involving the skin
only. Other surgical site infections aremore serious and can involve tissues
under the skin, organs, or implanted
material. Dr.T.V.Rao MD 2
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Surgical site infections
Surgical site infections
have been shown to
compose up to 20% of
all of healthcare-associated infections. At
least 5% of patientsundergoing a surgical
procedure develop asurgical site infection
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When the Infection occurs
Surgical site infectionmay range from aspontaneously limitedwound discharge within710 days of anoperation to a life-threateningpostoperative
complication, such as asternal infection afteropen heart surgery
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How Surgical Infections caused
Most surgical site infections are
caused by contamination of an
incision with microorganisms fromthe patient's own body during
surgery. Infection caused by
microorganisms from an outsidesource following surgery is less
common. Dr.T.V.Rao MD 5
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surgical site infections
3rd most common nosocomial infection
14-16%
Most common nosocomialinfection among surgery
patients 38%
2/3 incisional1/3 organ
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SSIs: Magnitude of the Problem
in USA
SSIs occur in 2.6% of all surgeries =
1.5 million SSIs annually SSIs are the second most common HAI LOS in hospital increases by 7.5 days
Attributable cost: $25,546 (range $1783
to $134,602)
U.S. National Cost: $130-$845million/year
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Epidemiology:
SSI data 2006-2011
Surgical site infections: are the third most prevalent HCAI in hospital
inpatients are present in 1% of hospital inpatients surveyed
(2011) account for 1.4% of overall HCAI incidence in
England
developed in 10% of large bowel operation cases* are largely preventable*this figure applies to procedures tracked under the nationalSSI surveillance programme
Information on this slide updated June 2012
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Risk Factors for SSI: The Patient
Age
Nutritional status
Diabetes
Nicotine use
Obesity
Coexistent infection
Colonization
Altered immune response
Long preoperative stayDr.T.V.Rao MD 9
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Risk Factors for SSI: Pre- and
Intraoperative
Inappropriate use of antimicrobial prophylaxis
Infection at remote site not treated prior to surgery
Shaving the site vs. clipping
Long duration of surgery Improper skin preparation
Improper surgical team hand antisepsis
Environment of the room (ventilation, sterilization)
Surgical attire and drapes
Asepsis
Surgical technique: hemostasis, sterile field
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Pathogenesis
VirulenceBacterial dose
Impairedhost resistance
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Surgical Infection Prevention
Project Started in August 2002, by the Centers for Medicare
& Medicaid Services (CMS) and the Centers forDisease Control and Prevention (CDC)
Based on 2 findings: Estimates indicate that 40-60% of all SSIs
are preventable
Overuse, underuse, improper timing, and misuseof antibiotics occurs in 25-50% of operations
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Selected Surgical Procedures
Increases the Risk Cardiac
Coronary Artery Bypass Graft (CABG)
Colon
Hip & Knee Arthroplasty
Abdominal & Vaginal Hysterectomy
Vascular Surgery:
Aneurysm repair
Thromboendarterectomy
Vein Bypass
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Important Definitions
Colonization Bacteria present in a wound with no signs or
symptoms of systemic inflammation
Usually less than 105 cfu/mL Contamination
Transient exposure of a wound to bacteria
Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours
SSI prophylaxis best strategy
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CDC on Skin Preparation
Require patients to shower or bathe with anantiseptic agent on at least the night before theoperative day. Cat IB
Thoroughly wash and clean at and around theincision site to remove gross contamination before
performing antiseptic skin preparation. Cat IB
Use an appropriate antiseptic agent for skinpreparation. Cat IB
Apply preoperative antiseptic skin preparation in
concentric circles moving toward the periphery. Theprepared area must be large enough to extend theincision or create new incisions or drain sites, ifnecessary. Cat II
Guideline for Prevention of Surgical Site Infection, 1999. HICPAC, Centers for Disease Control.
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AORN on Skin Preparation
The surgical site and surrounding areas should be clean. The skin around the surgical site should be free of soil and
debris. Removal of superficial soil, debris, and transientmicrobes before applying antiseptic agent(s) reduces therisk of wound contamination by decreasing the organic
debris on the skin.
Cleansing should be accomplished by any of the followingmethods before surgical skin preparation:
Patient showering and/or shampooing before arrival in thepractice setting
Washing the surgical site before arrival in the practice setting, or
Washing the surgical site immediately before applying theantiseptic agent in the practice setting
Standards, Recommended Practices, and Guidelines, 2005 Edition. AORN, Denver, CO.
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AORN on Skin Preparation (contd)
When indicated, the
surgical site and
surrounding area should be
prepared with an antiseptic
agent Antiseptic agents should
be.used in accordance with
the manufacturers written
instructions. Antiseptic
agent(s) should have a broadrange of germicidal action.
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Many Disinfectants
Variance in protocols and practice
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Contd;
Infection
Systemic and local signs of
inflammationBacterial counts 105 cfu/mL
Purulent versus nonpurulent
Surgical wound infection is SSI
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Preoperative phase
(hair removal)
Do not routinely use hair removal
Do not use razors for hair removal, as theyincrease the risk of surgical site infection
If hair has to be removed, use electric
clipperswith a single-use head on the day of
surgery
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Criteria for defining SSIs
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Further Classification
Etiology
a) Primary
The wound is the
primary site of infection
b)Secondary
Infection arises
following acomplication that is notdirectly related towound
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Contd;
Timea) Early
Infection presents within 30 days of
procedure
b) Intermediate
Occurs between one and three months
c) Late
Presents more than three months after
surgeryDr.T.V.Rao MD 23
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Contd;
Severitya) Minor
Wound infection is described as minor when
there is discharge without cellulitis or deep tissuedestruction
b) major
When there is pus discharge with tissue
breakdown , Partial or total dehiscence of thedeep fascial layers of wound or if systemic illnessis present.
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Mi bi l
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Microbiology
Nature of the Isolates
A major study
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Preoperative factors
influencesPreoperative antiseptic showering
Preoperative hair removal
Patient skin preparation in theoperating room
Preoperative hand/forearmantisepsis
Antimicrobial prophylaxisDr.T.V.Rao MD 26
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Preoperative antiseptic showeringDecreases skin microbial colony counts
No evidence of benefit to reduce SSI rates
Preoperative hair removal
Shaving:@ immediately before the operation: SSI rates 3.1%
@ shaving within 24 hours preoperatively: 7.1%
@ having performed >24 hours: SSI rate > 20%.
Depilatories:
@ lower SSI risk than shaving or clipping
@ hypersensitivity reactions
How to Prepare the Patients
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Symptoms include:
Redness and pain
around the area
where you hadsurgery
Drainage of cloudy
fluid from yoursurgical wound
Fever
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Changing a dressing
Before you start, make sure you havegauze pads, a box of medical gloves,
surgical tape, a plastic bag, and
scissors. Then:
Prepare supplies by opening the gauze
packages and cutting new tape strips. Put on medical gloves.
Loosen the tape around the old dressing.
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How to Deal with Problem
Inspect the incision for signs of infection.
Hold a clean, sterile gauze pad by the corner
and place over the incision.
Tape all four sides of the gauze pad.
Put all trash, including gloves, in a plastic bag.
Seal plastic bag and throw it away. Wash your hands.
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How to Deal with Problem
Remove the old dressing.
Remove the gloves. At this point,
clean the incision if your doctor toldyou to do so.
(See instructions below.)
Wash your hands, and put on
another pair of medical gloves
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Cleaning an incision
To clean the incision:
Gently wash it with soap and water to removethe crust.
Do not scrub or soak the wound. Do not use rubbing alcohol, hydrogen peroxide,
or iodine, which can harm the tissue and slowwound healing.
Air-dry the incision or pat it dry with a clean,fresh towel before reapplying the dressing.
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Do not Don't expose your
incision to direct sun for 3
to 9 months after surgery.
As an incision heals, the
new skin that is formed
over the cut is very
sensitive to sunlight and
will burn more easily than
normal skin. Bad scarring
could occur if you get
sunburn on this new skin.
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Preparing to Collecting the Swabs from
Wounds
The person collecting
specimens should
decontaminate hands to
reduce the risk of transfer
of transient organisms on
the healthcare workers
hands to the patient.
Apply gloves (remove
dressing as appropriate)
to protect the health care
workers hands.
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Ideal way to Collect the Wound Swabs
The wound should be cleansed with sterile
saline to irrigate any purulent debris (Stotts
2007) to achieve a clean culture site and to
avoid obtaining a culture from the pus on thesurface of the wound. Moisten the swab with
sterile saline before taking sample. In dry
wounds a moistened swab will attach bacteriamore effectively.
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Collecting a SWABS for Bacterial
Culturing
Always take a swab from a newly cleaned
wound.
Cleanse with normal saline or sterile water
Take a swab by moving in a Z pattern over
the wound and turning the swab at the same
time
Punch biopsy (Physician only)
Do Not swab necrotic or slough tissue
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Collecting the Swab
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*When to order the Culturing wounds
*Culture swab of a
wound should
only be taken ifclinical infection is
suspected.
Or else the results
are misleading
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Details of the Wound and Antibiotic Therapy should
be included in the Requests to Laboratory
The details regarding the wound should
be recorded on the request form-
Document condition of wound and
evidence of infection including clinical
symptoms any antibiotic treatment the
patient on must be recorded, Clinicaldetails will assist the microbiologist in
making an accurate diagnosis.
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Collect the Specimens with Optimal
care and Scientific Spirit
Properly collected
specimens will give
optimal benefit in
proper identificationof the causative
organisms and
appropriatedAntibiotic
suggestions.
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Wound Cleansing
- Normal Saline orSterile Water
Irrigate with 20-
30 ml syringe
Use 18 angiocath
4-6 inches above
the wound
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Prophylactic antibiotics
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Prophylacticantibioticsindicated
Therapeutic antibiotics
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ABX
Once the incision is made,antibiotic delivery to the
wound is impaired.
Must give before incision!
Do Remember
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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
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P ti h
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Preoperative phase
(antibiotic prophylaxis)
Give antibiotic prophylaxis before:- clean surgery for the placement of a prosthesis or
implant- clean-contaminated surgery- contaminated surgery
Do not routinely use for clean non-prostheticuncomplicated
surgery
Use local antibiotic formulary and consider adverseeffects
Consider prophylaxis on starting anaesthesia, orearlier for operations using a tourniquet
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Standardized infection ratio
The standardized infection ratio (SIR) is a
summary measure used to track HAIs at a
national, state, or facility level over time. The
SIR adjusts for the fact that each healthcarefacility treats different types of patients. For
example, the experience with HAIs at a
hospital with a large burn unit cannot bedirectly compared to a facility without a burn
unit.
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Learn to Calculate the Infection Rates at
you Hospitals
The SIR compares the actual number
of HAIs in a facility or state with the
baseline U.S. experience (i.e.,standard population), adjusting for
several risk factors that have been
found to be most associated withdifferences in infection rates.
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S G d B t I f ti
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Say Good Bye to Infections
Just Wash your Hands
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Visit me for More Articles of Interest on FACEBOOK
Raos Infection Care - Raos Microbiology
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Programme Created by Dr.T.V.Rao MD
for Medical and Health Care
Professionals in the Developing World
Email
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