-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
1/39
Management of surgical site infectionsManagement of surgical site infections
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
2/39
Surgical site infection (SSI)management of wound infectionsmanagement of wound infections
The strategy for wound infection management is toprevent or minimize the risk of infection.
An action or set of actions intentionally taken to reducethe risk of SSI.
Reducing opportunities for microbial contamination of the
patients tissues or sterile surgical environment. Applied to the patient preparation, Surgical team
members educated in aseptic technique, care of Theatreenvironment and instruments, optimize surgicaltechnique.
the Centers for Disease Control and Prevention (CDC)
and Healthcare Infection Control Practices AdvisoryCommittee (HICPAC) presents recommendations for theprevention of surgical site infections (SSIs), formerly
called surgical wound infections.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
3/39
CDC GUIDELINE: PREVENTION OF SSICDC GUIDELINE: PREVENTION OF SSI
Categorizing RecommendationsCategorizing Recommendations
IA Strongly recommended for implementationand supported by well-designedexperimental,clinical or epidemiological studies & should beadapted by all practices .
IB Strongly recommended for implementationand supported by some experimental, clinical, orepidemiological studies and strong theoreticalrationale.
II Suggested for implementation and supported
by suggestive clinical or epidemiological studies ortheoretical rationale.
No recommendation; unresolved issues, practices&evidence for which are insufficient.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
4/39
CDC GUIDELINE: PREVENTION OF SSICDC GUIDELINE: PREVENTION OF SSI
Preoperative circumstances:Preoperative circumstances:
Patient preparation.Patient preparation.
Antimicrobial prophylaxis.Antimicrobial prophylaxis.
Surgical team members.Surgical team members.
Management of infected or colonized surgicalManagement of infected or colonized surgicalpersonnelpersonnel (staff).(staff).
Intraoperative Recommendations:Intraoperative Recommendations:
Surgical drapes.Surgical drapes.
wound care.wound care.
Postoperative Recommendations:Postoperative Recommendations: Incision Care.Incision Care.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
5/39
Preoperative circumstancesPreoperative circumstances
Patient preparationPatient preparation CategoryIA criteria
Identify and treat all infections remote from the surgical site.
Do not remove hair unless it will interfere with the operation .
CategoryIB criteria
Adequately control serum blood glucose levels .
Encourage tobacco cessation
Do not withhold necessary blood products from surgical patients asa means to prevent SSI. .
Pre-operative shower or bathe with an antiseptic agent on at least
the night before the operative day Thoroughly wash and clean at and around the incision site &Use an
appropriate antiseptic agent .
CategoryIIcriteria:
Keep preoperative stay in hospital as short as possible while allowing foradequate preoperative preparation of the patient.
Apply preoperative antiseptic skin preparation in concentric circles&Theprepared area must be large enough to extend the incision or create newincisions or drain sites,
No recommendation
Taper or discontinue systemic steroid use before elective surgery .
enhance nutritional support .
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
6/39
Hair RemovalHair Removal
PrePre--operative Shavingoperative Shaving
Shaving the surgical site with a razor
induces small skin lacerations:
Potential sites for infection.
Disturbs hair follicles which are oftencolonized with S. aureus
Risk greatest when done the night
before.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
7/39
Shaving of operative siteShaving of operative site
Shaving ProtocolShaving Protocol SSIRiskSSIRisk
Hair not removed 0,6%
Hair removed by razor night
before
5,6%
Razor < 24hrs before surgery 7,1%
Razor > 24hrs before surgery > 20%
Clippers right before surgery 1,8%
Clippers night before surgery 4,0%
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
8/39
Preoperative circumstancesPreoperative circumstances
Antimicrobial prophylaxisAntimicrobial prophylaxis
To reduce the microbial burden of intra-operativecontamination to a level that cannot overwhelm hostdefences.
Category 1A Select an antimicrobial agent safe, inexpensive, and bactericidal
with efficacy against expected pathogen . Administer IV& timed to achieve adequate bactericidal serum
levels during operation and for few hours after incision closed .
Before colorectal elective operations, in addition to IVantimicrobial drugs, mechanically prepare the colon withenemas and cathartic agents; administer nonabsorbable oralantimicrobial agents in individual doses the day before surgery .
For cesarean sections in patients at high risk administer IV
antimicrobial agent immediately after cord is clamped. Category 1B
-Do not routinely use vancomycin for prophylaxis
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
9/39
Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions
Which cases benefit?Which cases benefit?
Which drug should you use?Which drug should you use?
When should you start?When should you start?
How much should you give?How much should you give?
How long should antibiotics be continued?How long should antibiotics be continued?
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
10/39
Antibiotic ProphylaxisAntibiotic ProphylaxisDemonstrated BenefitDemonstrated Benefit
All clean-contaminated procedures; these include
penetration of the gastrointestinal tract, whether by
penetrating trauma or related to a pathological organ
event (e.g. ruptured appendix, perforated colonic
diverticulum) prior to the development of clinical
peritonitis.
Clean operations with foreign body implant(e.g.
vascular, cardiac and orthopaedic operations), and those
without foreign body implants especially hernia repair,
breast surgery, median sternotomy, vascular surgery
involving the aorta and the lower extremities, and
craniotomy.
For contaminated & dirty 0perations(e.g. acute
cholecystitis, empyema , ascending cholangitis or liver
abscess , perforated appendix with evidence of local or
generalised peritonitis and/or intraabdominal abscess,
antibiotic given as part of treatment (for a longer
duration ).
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
11/39
Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions
Which cases benefit?Which cases benefit?
Which drug should you use?Which drug should you use?
When should you start?When should you start?
How much should you give?How much should you give?
How long should antibiotics be continued?How long should antibiotics be continued?
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
12/39
Operation Expected Pathogens Recommended
Antibiotic
Orthopedic surgery,
neurosurgery , breast
surgery Cardiothoracicsurgery
S aureus, coagulase-negativestaphylococci
Cefazolin 1-2 g IV OR
Cefuroxime 1.5 g IV OR
Vancomycine
Gastroduodenal surgery Gram-negative bacilli andstreptococci , anaerobic
Cefazolin 1-2 g IV
Colorectal surgery Gram-negative bacilli andanaerobes
Cefoxitin 1-2 g plus oral Neomycin1 g and oral Eerythromycin 1 g(start preoperatively for 3 doses)
Appendectomy, biliary
procedures
Gram-negative bacilli andanaerobes
Cefazolin 1-2 g OR
Cefoxitin 2 g IV
Vascular surgery S aureus, Staphylococcus
epidermidis, gram-negative bacilliCefazolin 1-2 g
Head and neck surgery S aureus, streptococci, anaerobesand streptococci
Cefazolin 1-2 g
Amoxiclav 1.2 g IV
Obstetric and
gynecological
procedures
Gram-negative bacilli, enterococci,anaerobes, group B streptococci
Cefazolin 1-2 g
Urology procedures Gram-negative bacilli Cefazolin 1-2 g
Contaminated Surgery
Ruptured viscus &
traumatic wound
Enteric gram-negative
bacilli, anaerobes,
Enterococci & S. aureus, group Astrep, clostridia
Cefoxitin or Cefazolin / Gentamicin
OR Metronidazole plus Gentamicin
IV
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
13/39
Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions
Which cases benefit?Which cases benefit?
Which drug should you use?Which drug should you use?
When should you start?When should you start?
How much should you give?How much should you give?
How long should antibiotics be continued?How long should antibiotics be continued?
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
14/39
Antibiotic ProphylaxisAntibiotic ProphylaxisProper Timing of Antimicrobial AdministrationProper Timing of Antimicrobial Administration
The optimal concentration in the serum/tissueat the time of the incision.
It is important to maintain therapeutic level inthe serum/tissue throughout the operation.
If the surgical procedure is longer than the half-life of the drug, re-dosed during the procedure,(a second dose only given if the operation lastsfor longer than 2 - 3 hours ).
According to the most recent Medicalrecommendations the drug should be givenbetween 30 minutes and two hours before thetime of surgical incision.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
15/39
Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions
Which cases benefit?Which cases benefit?
Which drug should you use?Which drug should you use?
When should you start?When should you start?
How much should you give?How much should you give?
How long should antibiotics be continued?How long should antibiotics be continued?
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
16/39
Antibiotic ProphylaxisAntibiotic Prophylaxis
Dose of Antibiotic for ProphylaxisDose of Antibiotic for Prophylaxis
Always give at least a full therapeutic dose of
antibiotic.
Consider the upper range of doses for large
patients and/or long operations.
Consider repeating doses for long operations.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
17/39
Prophylactic AntibioticsProphylactic AntibioticsQuestionsQuestions
Which cases benefit?Which cases benefit?
Which drug should you use?Which drug should you use?
When should you start?When should you start?
How much should you give?How much should you give?
When should antibiotics be stopped?When should antibiotics be stopped?
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
18/39
Prophylactic AntibioticsProphylactic AntibioticsLimiting the Duration of AntimicrobialLimiting the Duration of Antimicrobial
AdministrationAdministration
Discontinuation of the antibiotic within 24
hours after surgery is recommended for the
following reasons:
Use of the prophylaxic antimicrobial agent after
this period has not been shown to improvesurgical site infection rates and increases the cost
of care unnecessarily .
Indiscriminate & prolong use of antimicrobials
agents can lead to the development of antibiotic-
resistant microorganisms. Increased antibiotic-associated complications:
.Clostridium difficile Enterocolitis
.Colonization with MRSA
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
19/39
Prolonged prophylaxis
Wound infectionwith
Resistant organismsMRSA, pseudomonas
Risk of nosocomial
Infections CDAD
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
20/39
Preoperative circumstancesPreoperative circumstances
Surgical team membersSurgical team members
CategoryIB
Keep fingernails short.
Perform a preoperative surgical scrub for at least 2
to 5 minutes using an appropriate antiseptic.
After performing the surgical scrub, keep hands up
and away from the body.
use a sterile towel to dry the hands and put on asterile gown and gloves.
CategoryII Clean underneath each fingernail prior to performing
the first surgical scrub of the day.
Do not wear arm/hand jewelry.
No recommendation wearing nail polish.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
21/39
Preoperative circumstancesPreoperative circumstances
Management of infected or colonized surgicalManagement of infected or colonized surgical
personnelpersonnel (staff)(staff)
CategoryIB
Routine exclusion of personnel colonized by
organisms, such as Saureus or group A
streptococci, is not necessary unless they are
specifically linked to dissemination of such
organisms.
Personnel with skin lesions that are draining are to
be excluded from duty until treated and the infection
has resolved.
Educate and encourage surgical personnel regarding
reporting illness of transmissible nature to
supervisory and occupational health personnel.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
22/39
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
23/39
Intraoperative RecommendationsIntraoperative Recommendations
Surgical drapesSurgical drapes
CategoryIB Masks should cover the mouth and nose & worn in
the operating room if sterile instruments are exposedand throughout the surgical procedure.
The hair on the head and face is to be covered with a
hood or cap. Liquid-resistant sterile surgical gowns and sterile
gloves are to be worn by scrubbed surgical teammembers.
Visibly soiled gowns are to be changed.
Shoe covers are not necessary.
No recommendation Restriction of scrub suits to the operating theater.
Covering the scrub suits when outside the theater.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
24/39
Intraoperative RecommendationsIntraoperative Recommendations
wound carewound care
CategoryIA:
Asepsis is necessary in the insertion of indwellingcatheters, such as intravascular, spinal, or epiduralcatheters, and subsequent infusion of drugs.
CategoryIB
Handle tissues gently with good homeostasis,minimize foreign bodies, and minimize
devitalized tissue and dead space. For Class III and IV wounds, use delayed closure
or leave the wound incision open to heal bysecondary intention.
If draining of a wound is necessary, use a closedsuction drain the drain exit should be via
separate incision distant from the wound.Remove the drain as soon as possible.
CategoryII
Assemble sterile equipment and solutionsimmediately prior to use.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
25/39
Postoperative RecommendationsPostoperative Recommendations
Incision CareIncision Care
CategoryIB
Incisions should be protected with a sterile dressing for 24-
48 hours.
Wash hands before and after dressing changes and any
contact with the surgical site.
CategoryII
Use sterile technique for wound dressing change.
Educate the patient and relatives regarding wound care
symptoms of SSIs and the need to report such problems.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
26/39
Treatment of surgical site infectionsTreatment of surgical site infections
Treating wound infections depends on the nature of thewound, degree of infection, and the bacteria responsiblefor the infection.
Open the wound and allow it to drain:
Remove sutures and staples local to the site of infection.
Skin and subquatenous tissues in involved area opened& exam to assess its integrity and for a deep spaceinfection & to exclude the underlying fascial dehiscence.
Evacuate the pus.
Swab for c/s.
Cleansing the wound: by irrigating the wound withsterile (clean) water or normal saline &It may be doneusing high pressure with a needle or catheter and a largesyringe , Germ-killing solutions may also be used toclean the wound like Hydrogen peroxide.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
27/39
Treatment of surgical site infectionsTreatment of surgical site infections
Debridement: to clean and remove objects, dirt, or dead skinand necrotic tissues from the wound area.
Dressing the wound : to protect the wound from furtherinjury and infection. These may also help provide pressure todecrease swelling. Dressings may come in different forms.Dressing changes allow the tissues to granulate.
Close the wound.
Antibiotics to fight the infections, patient high risk fordissemination of infection (i.e. diabetics ; Immnuno-compromised, if prosthetics involved, if patient has signs ofsystemic toxicity or if surrounding area of soft tissue erythemaand edema.
A tetanus vaccine booster shot may be indicated to preventthe occurrence of tetanus.
Other treatment: Controlling or treating the medical conditionthat causes poor wound healing & treat complications.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
28/39
Choice of antibioticChoice of antibiotic
1-post operative wound infection without
sepsis (no GIT,FGT)
Cephalexin 500mg po q6 h
amoxiclav 500 mg po q8 h Dicloxacillin 500 mg po q6 h
+/-
Ciprofloxacin 500 mg po q12 h
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
29/39
Choice of antibioticChoice of antibiotic
2) Post. Op. wound infection with sepsis
(surgery involving GIT,FGT)
Cefoxitin 1gm iv q6h or
Cefotaxime 1gm iv q 8 h, Ceftriaxone 1-2 gm iv q 24 h
+
metronidazole iv q8h or
imipenum 500 mg iv q6 h.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
30/39
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
31/39
Traumatic wound infectionIntroduction
Traumatic injuries have a potential for serious bacterialwound infections, including gas gangrene and tetanus,and these in turn may lead to long term disabilities,chronic wound or bone infection, and death.
Wound infection is particularly of concern wheninjured patients present late for definitive care, or indisasters where large numbers of injured survivorsexceed available trauma care capacity.
Appropriate management of injuries is important to
reduce the likelihood of wound infections.
The following core principles and protocols provideguidance for appropriate prevention and management
of infected wounds.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
32/39
Management of traumatic wound infection
Core Principles
1. Never close infected wounds:
Systematically perform wound toilet and surgical
debridement until the wound is completely clean.
2. Do not close contaminated wounds and clean
wounds that are more than six hours old:Surgical toilet, leave open and then close 48 hours later
(delayed primary closure).
3. Antibiotics:
They are necessary but not sufficient and need to be
combined with appropriate debridement and wound
toilet .
3. Use of topical antibiotics and washing wounds
with antibiotic solutions are not
recommended.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
33/39
Management of traumatic wound infection
Core Principles
5. To prevent wound infection: Restore breathing and blood circulation as soon as
possible after injury.
Warm the victim and at the earliest opportunity provide
high-energy nutrition and pain relief. Do not use tourniquets.
Perform wound toilet and debridement as soon as
possible (within 8 hours if possible).
Respect universal precautions to avoid transmission of
infection.
Give antibiotic prophylaxis to victims with deep wounds
and other indications.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
34/39
Protocols
Protocol 1: Wound toilet and surgical debridement
Protocol 2: Management of tetanus-prone wounds
Protocol 3: Antibiotic prophylaxis and treatment
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
35/39
Protocols
Protocol 1: Wound toilet and surgical
debridement
1.1. Wash the woundWash the wound with large quantities of soap and
boiled water for 10 minutes, and then irrigate the
wound with saline.
2. DebridementDebridement: mechanically remove dirt particles
and other foreign matter from the wound and use
surgical techniques to cut away damaged and dead
tissue, Irrigate the wound again. If a local anesthetic
is needed, use 1% lidocaine withoutepinephrine.
3. Leave the wound openLeave the wound open. Pack it lightly with dampsaline disinfected or clean gauze and cover the
packed wound with dry dressing. Change the
packing and dressing at least daily.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
36/39
Protocol 2: Management of tetanus-prone
wounds
Wounds more than 6 hours before surgicaltreatment of the wound or show one or more of thefollowing: a puncture-type wound, a significantdegree of devitalized tissue, clinical evidence ofsepsis, contamination with soil/feces likely to
contain tetanus organisms, burns, frostbite, andhigh velocity missile injuries.
For patients with tetanus-prone injuries, WHOrecommends TT or Td and TIG.
When tetanus vaccine and tetanus immunoglobulinare administered at the same time, they should beadministered using separate syringes andseparates sites.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
37/39
Protocol 2: Management of tetanus-prone
wounds
Tetanus vaccine
ADULT and CHILDREN overADULT and CHILDREN over 1010 years:years:
Active immunization with tetanus toxoid (TT) or with tetanus and
diphtheria vaccine (Td)
1 dose (0.5 ml) by intramuscular or deep subcutaneous injection. Follow
up: 6weeks, 6 months.CHILDREN underCHILDREN under 1010 years:years:
Diphtheria and tetanus vaccine (DT)
0.5 ml by intramuscular or deep subcutaneous injection. Follow up at
least 4 weeks and 8 weeks.
Tetanus immune globulin
ADULT and CHI
LDADU
LT and CHI
LD Tetanus immunoglobulin (human) 500 units/vial
250 units by intramuscular injection, increased to 500 units if any of the
following conditions apply: wound older than 12 hours; presence, or risk
of, heavy contamination; or if patient weight more than 90 kg.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
38/39
Protocol 3: Antibiotic prophylaxis and
treatment
Antibiotic prophylaxisAntibiotic prophylaxis
Contaminated wounds, penetrating wounds, abdominal trauma,compound fractures, lacerations greater than 5 cm, wounds withdevitalized tissue, high risk anatomical sites such as hand or
foot.
Recommended prophylaxis consists of penicillinG andmetronidazole given once.
Penicillin G ADULT: IV8-12million IU once. CHILD: IV200,000IU/kg once.
Metronidazole ADULT: IV1,500 mg once (infused over 30min). CHILD: IV20 mg/kg once.
-
8/6/2019 Surgical Site Infection )SSI)2 Fffffffffffffffffffffffffffff Preventive Measure - Copy
39/39
Protocol 3: Antibiotic prophylaxis and
treatment
Antibiotic treatmentAntibiotic treatment
If infection is present or likely, administer antibiotics via
intravenous and not intramuscular route.
PenicillinG and metronidazole for 5-7 days provide good
coverage.
Penicillin G ADULT: IV1 - 5 MIU every 6 hours. After 2 days it is possible to use oral Penicillin: Penicillin V 2
tablets every 6 hours.
CHILD: IV100mg/kg daily divided doses (with higher doses in
severe infections),
In case of known allergy to penicillin use erythromycin
Metronidazole ADULT: IV500 mg every 8 hours (infusedover20 minutes).
CHILD: IV7.5 mg/kg every 8 hours.