L-20 Surgical Site Infections (SSI) Overview

Surgical Infection Overview

• About 0.5-5% of patients undergoing surgery experience an infection at or near the surgical site
• Up to 60% of surgical site infections are preventable
• Purulent discharge forms in open wounds
• Erythema and pus is visible in closed wounds
• Organisms isolated from surgical incision

Surgical Site Infection (SSI) Types

• Superficial incisional: Infection within 30 days involving only skin and subcutaneous tissue
• Deep incisional: Infection within 30 days if no implant or 1 year if implant is in place, related to the procedure and involving deep soft tissues
• Organ Space SSI: Infection within 30 days if no implant or 1 year if implant is in place, related to the procedure and involving deep soft tissues

Superficial Incisional SSI Criteria

• Purulent drainage from surgical incision, with or without lab confirmation
• Organisms isolated from surgical incision culture
• Pain, tenderness, swelling, redness or heat
• Superficial incision is deliberately opened by surgeon unless culture is negative
• Diagnosis by surgeon
• Stitch abscess, and episiotomy/newborn circumcision site and infected burn do not constitute superficial SSI

Deep Incisional SSI Criteria

• Purulent drainage from the deep incision, not from the organ/space
• Deep incision dehisces spontaneously or is deliberately opened and a patient has fever (>38°C), localized pain or tenderness, unless culture is negative.
• An abscess, or evidence of infection are found on direct examination, during reoperation, or by histopathologic or radiologic examination.
• Diagnosis made by surgeon or attending physician.

Organ Space SSI Criteria

• Purulent drainage, but not from organ/space component
• Deep incision that spontaneously dehisces or is deliberately opened with fever (>38°C), localized pain/tenderness, unless culture is negative
• Abscess evidence of infection
• Diagnosis made by surgeon or attending physician

Risks Factors

• Intrinsic, patient-related includes non-modifiable and modifiable factors
• Extrinsic factors are procedure related

Non-Modifiable Patient Risks

• Increased age
• Recent radiotherapy
• History of skin/soft tissue infections

Modifiable Patient Risks

• Diabetes
• Obesity
• Alcoholism
• Current smoker
• Albumin <3.5 mg/dL
• Total bilirubin >1.0 mg/dL
• Immunosuppression

Procedure Risks

• Emergency
• Increased complexity
• Higher wound classification

Facility Risks

• Inadequate ventilation
• Increased OR traffic
• Contaminated surfaces
• Non-sterile equipment

Preoperative Risks

• Pre-existing infection
• Inadequate skin preparation
• Inappropriate choice
• Timing and weight-based dosing of antibiotics
• Hair removal method
• Poor glycemic control

Intraoperative Risks:

• Longer procedure duration
• Blood transfusion
• Breach of asepsis
• Inappropriate antibiotic re-dosing
• Inadequate gloving
• Inappropriate surgical scrub
• Poor glycemic control

The National Healthcare Safety Network (NHSN)

• Wound class III/IV, ASA 3-5, OR time >75th percentile duration, is highest risk for surgical site infection

Surgical Wound Classification & Risk

• Class I: Clean has less than 2% risk
• Class II: Clean-contaminated has less than 10% risk
• Class III: Contaminated has ~20% risk
• Class IV: Dirty/Infected has ~40% risk

Class I: Clean

• Surgical wound with no breach of respiratory, GI, GU or genital tracts and no inflammation
• Hernia repair
• Thyroidectomy
• CABG
• Mastectomy
• Lumpectomy
• Total knee replacement
• Total hip replacement
• Port placement
• Axillary lymph node dissection

Class II: Clean-Contaminated

• Surgical wound with controlled entrance of the respiratory, GI, GU, or genital tracts without a major break in technique
• Small bowel resection
• Lobectomy (lung)
• Hysterectomy
• Colectomy
• Colostomy Reversal
• Roux-en-Y Gastric Bypass
• Whipple
• Laryngectomy
• TURP

Class III: Contaminated

• Surgical wound open, fresh, and/or accidental with a major break in sterile technique and/or uncontrolled/gross spillage from the Gl tract
• Surgical wound with acute, non purulent inflammation is met
• Cholecystectomy for acute cholecystitis
• Appendectomy for non-perforated appendicitis
• Nonsterile equipment or debris on operative field
• Small bowel resection for infarcted or necrotic bowel

Class IV: Dirty/Infected

• Wound that is old, and/or accidental/traumatic with a major break in sterile technique and/or uncontrolled/gross spillage from the Gl tract
• Peritonitis
• Appendectomy for perforated appendicitis
• Repair of perforated gastric ulcer
• Repair of perforated small bowel
• Open fracture repair

Guidelines and Interventions

• Preoperative bathing
• Smoking cessation for 4-6 weeks before surgery
• Glucose control
• MRSA screening
• Bowel preparation
• Hair removal
• Skin preparation
• Surgical hand scrub
• Surgical attire
• Antibiotic prophylaxis
• Intraoperative normothermia
• Wound protectors
• Antibiotic sutures
• Gloves
• Instruments
• Wound closure
• Supplemental oxygen
• Topical antibiotics
• Wound care

Preoperative Bathing

• A full body shower at least the evening before the operative day is advised

Perioperative Glycemic Control

• Maintain blood glucose below 200 mg/dL
• ACS recommends 110-150 mg/dL.
• Cardiac surgery goal is <180 mg/dL

Handwashing

• Scrubbing the hands with antimicrobial soap and water
• Use of alcohol-based hand rub solutions

Hyperoxia Administration

• Give patients undergoing general anesthesia with endotracheal intubation 80% FiO2 intraoperatively, and immediately postoperatively

Skin Preparation

• Prep skin with an alcohol-based antiseptic solution unless contraindicated
• Avoid hair removal, use clippers if needed, and do not shave

Normothermia

• Use warming devices to maintain a normal body temperature

Antibiotics Administration

• Prevent surgical site infection, but are not necessarily enough alone
• Use for prophylaxis
• Administer IV antibiotics 60-120 minutes before incision, and not beyond 24 hours
• For procedures with more infection or if foreign material if implanted, give 30-60 mins before operation, high blood loss >1.5L may need extra doses
• Preoperative oral antibiotics are given with mechanical bowel preparation to adult patients having colorectal surgery
• Administer prophylactic IV antibiotics before skin incision for cesarean sections

Antibiotics Treatment

• Do not apply antimicrobial agents to surgical incision for SSI prevention
• In orthopedic and cardiothoracic cases, treat Staph aureus carriers with intranasal mupirocin 2% ointment with/without chlorhexidine body wash

General Principle of Surgical Infection, Aseptic Technique

• Maintain a sterile environment to prevent infections

General Principle of Surgical Infection, Hand Hygiene

• Ensure proper hand hygiene practices before and after patient contact

General Principle of Surgical Infection, PPE

• Use appropriate PPE to reduce the risk of infection

General Principle of Surgical Infection, Environmental Cleaning

• Regularly clean and disinfect the surgical environment and equipment

General Principle of Surgical Infection, Patient Screening

• Preoperatively screen for potential infections to identify and address risks early

Antimicrobial Prophylaxis

• Choose appropriate antimicrobial agent based on the surgery type and patient factors
• Most common organisms in clean procedures are Staph aureus and coagulase negative staphylococci and clean contaminated procedures are gram negative rods and enterococci.
• Dose should be single and given only for less than 24 hours
• Adjust dose based on patient weight and renal function to avoid under or overdosing
• Limit antibiotic use to the perioperative period to reduce resistance
• Monitor the patient for adverse reactions.

Preoperative Prepping Process

• Patient Education is necessary to inform the patients of the procedure
• Skin Preparation using antiseptic agents to clean and reduce surface microbial load
• Shave or clip hair to lower infection risk
• Verify Consent
• Asses Patient Status fully to preemptively identify any risk factors

Staphylococcus Aureus Decolonization

• Screen for carriers of Staph aureus through nasal swabs.
• Staph incidence of colonization is 32%, and MRSA is 1.5%
• Use mupirocin ointment to decolonize nasal carriers
• Administer chlorhexidine gluconate baths to reduce skin colonization
• Maintain patient compliance - Chlorhexidine scrub/shower 7 days pre-op, nares (mupirocin) twice daily for 5 days
• Reassess status before surgery

Perioperative Normothermia

• Keep core temperature within normal range (37 C or 98.6 F)
• Loss of heat is due to radiation, conduction, evaporation or convection
• Use active warming devices - forced air warming blankets
• Monitor patient constantly through operation
• Pre-warm anesthesia patients to reduce risk of hypothermia
• Continue temperature monitoring and warming post-op in recovery room

Surveillance and Infection Program

• Collect and analyze data on surgical site infections (SSIs) to identify trends
• Identify infection clusters, baseline risks for infection, surgical specialties and surgeon data
• Implementation of Guidelines follows evidence-based guidelines such as CDC, NSQIP WHO, NHSN
• Regular audits ensure compliance
• Education and Training for healthcare staff in infection prevention
• Create a Feedback Mechanism to report infection incidents