surgical site infectionsprevention and care

8/22/2019 SURGICAL SITE INFECTIONS PREVENTION AND CARE

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SURGICAL SITE INFECTIONS

PREVENTION AND CARE

Dr.T.V.Rao MD

Dr.T.V.Rao MD 1


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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

Dr.T.V.Rao MD 44

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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Raos Infection Care - Raos Microbiology

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