Surgical Site Infections (SSI) PDF

SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 1 SURGICAL SITE INFECTION (SSI) operating, SSIs are infections of the tissues, organs, o...

SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 1 SURGICAL SITE INFECTION (SSI) operating, SSIs are infections of the tissues, organs, or spaces especially radical exposed by surgeons during performance of an invasive procedures procedure Staphylococcus Most common health care-associated infection following Colonization with aureus has a very surgery microorganisms high incidence of SSI postoperatively ○ Infection during the postoperative period covers Diabetes not only the surgical site infection but also other Smoking infections such as pulmonary infection, genitourinary infection but with recent data, SSI is still the number Coexistent infections at a remote body one cause of postoperative infection site Associated with significant morbidity and mortality Altered immune response ○ ICU admissions and prolonged hospital stay Length of preoperative stay Most common reason for unplanned readmission after Duration of surgical scrub surgery Skin antisepsis Centers For Disease Control and National Healthcare Preoperative shaving Safety Network defines SSI: Preoperative skin preparation ○ An infection related to a surgical procedure that Duration of operation occurs near the surgical site within 30 days (or up to Antimicrobial prophylaxis 90 days following surgery where an implant is Operating room ventilation involved) Inadequate sterilization of Operation instruments INCIDENCE Foreign material in surgical site Varies widely: 5% to 30% depending upon the operative Surgical drains site and wound classification Surgical technique Develops in 2% to 5% of patients undergoing inpatient ○ Poor hemostasis surgical procedures ○ Failure to obliterate dead SSI in middle to low income countries may be higher space compared with high income countries ○ Tissue trauma ○ May be due to resources such as income deficit Decreased overtime due to widespread prevention SCHWARTZ e orts RISK FACTORS FOR DEVELOPMENT OF SSIs PATIENT LOCAL MICROBIAL RISK FACTORS Older age Open Prolonged Patient and operation characteristics that may influence Immunosuppression compared to hospitalizatio the risk of surgical site infection development Obesity laparoscopic n (leading to The development of SSIs is related to 3 factors: Diabetes mellitus surgery nosocomial ○ The degree of microbial contamination of the Chronic Poor skin organisms) wound during surgery inflammatory preparation Toxin process Contamination secretion ○ Duration of the procedure Malnutrition of instruments Resistance to ○ Host factors such as diabetes, malnutrition, Smoking Inadequate clearance obesity, immune suppression and other underlying Renal failure prophylaxis (e.g., capsule disease states Peripheral vascular Prolonged formation disease procedure Anemia Local tissue RISK ASSESSMENT Radiation necrosis Younger and older Chronic skin disease Blood people have a Carrier state (e.g transfusion higher chance of chronic Hypoxia, AGE developing SSI as Staphylococcus hypothermia compared to carriage) young healthy Recent operation patients CATEGORIZATION OF HOSPITALS PATIENT If the patient is Primary Larger than rural health units morbidly obese or Secondary Most of the hospitals extremely Better set-ups of the operating Tertiary room as compared to primary and NUTRITIONAL malnourished, secondary STATUS operation will not Give proper antibiotics be done. Address nutritional status first before STUDY WELL & STAY HYDRATED! © MED TRANS  SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 2 SURGICAL WOUND CLASSIFICATION When you remove the inflamed Degree of contamination also dictates if there will be a Laparoscopic appendix, you will have some sort postoperative site infection appendectomy of contamination around the area of the cecum CLASS I/CLEAN The oral cavity is entered to An uninfected operative wound in which no Tonsillectomy remove the hypertrophied tonsil. inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not CLASS III/CONTAMINATED entered. Open, fresh, accidental wounds Clean wounds are primarily closed and, if necessary, Operations with major breaks in sterile technique (eg. drained with closed drainage open cardiac massage) Operative incisional wounds that follow nonpenetrating Gross spillage from the gastrointestinal tract, and (blunt) trauma should be included in this category if incisions in which acute, nonpurulent inflammation is they meet the criteria. encountered are included in this category Percentage of having post-operative site infection is 1.3 Chances of infection are 6.5 to 15.2% to 2.9% ○ Even if this is a clean surgery, you will still have Examples of Class III/Contaminated Wound some sort of infection. The organs involved are the Clean wounds (class I) include those in which no descending colon and sigmoid colon, infection is present; only skin microflora potentially Perforated where sacculations can be seen which contaminate the wound, and no hollow viscus that diverticulum/ are diverticulitis contains microbes is entered Diverticulitis There is pericolic inflammation and ○ Class I D wounds are similar except that a abscess collection. When endoscopic prosthetic device (e.g., mesh or valve) is inserted colonoscopy is done, air will be blown thus the succulations are seen as holes. Examples of Class I/Clean Wound Common among 60 years old, but can Modified radical Respiratory, alimentary, digestive also be seen among 30 years old mastectomy for an tract was not entered A very large stone in the gallbladder invasive ductal Only involves the skin and breast eroded the duodenum, then went down carcinoma tissue to the ileocecal part Any organ was not entered Gallstone ileus Inguinal hernia Enterotomy was done (opening of the Aims to close the hernial sac and part where the stone got stuck), and repair strengthen the inguinal floor tried to pull out the stone. During the In a blunt trauma in pediatric case, extraction, there is spillage of diagnostic laparoscopy was contents, thus is called contaminated. performed, where a lacerated spleen Diagnostic was seen. The spleen can be CLASS IV/DIRTY-INFECTED laparoscopy of the salvaged in this type of surgery. Old traumatic wounds with retained devitalized tissue spleen There is blunt trauma but has no and those that involve existing clinical infection or penetration in the abdominal wall perforated viscera and fascia, thus considered a clean The organisms causing postoperative infection were surgery. present in the operative field before the operation. The cause of injury is already infected. CLASS II/CLEAN-CONTAMINATED Chances of having infection is 7.1 to 40% An operative wound in which the respiratory, Dirty wounds (Class IV) include traumatic wounds in alimentary, genital, or urinary tracts are entered under which a significant delay in treatment has occurred and controlled conditions and without usual contamination in which necrotic tissue is present: Operations involving the biliary tract, appendix, vagina, ○ Presence of overt infection as evidenced by the and oropharynx are included in this category, provided presence of purulent material no evidence of infection or major break in technique is ○ Those created to access a perforated viscus encountered accompanied by a high degree of contamination Chances of having SSI is around 2.4 to 7.7% Examples of Class IV/Dirty-Infected Wound Examples of Class II/Clean-Contaminated Wound A streetsweeper who fell on the When you remove the gallbladder, Pierced stick on the gutter was pierced with a stick the process involves opening the thigh Laparoscopic from a broom. This is considered biliary tract as dirty-infected. cholecystectomy There is spillage of the contents A 19-year-old male, drinking with of the bile, leading to Gunshot wound his friends, obtained a gunshot contamination. wound STUDY WELL & STAY HYDRATED! © MED TRANS  SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 3 Some surgeons contest that when based you fire a bullet, it is sterile if microbiologic already inside the body, however testing method) in general, it is still considered as Incision opened dirty by the surgeon (or other SCHWARTZ designated Wound class, representative procedures, and expected infection clinician) rates because of EXAMPLES OF EXPECTED concern for WOUND CLASS CASES INFECTION RATES superficial SSI Hernia repair, breast Purulent Clean (class I) 1–2% biopsY drainage from Cholecystectomy, the deep Clean/ contaminated incision elective GI surgery 2.1–9.5% (class II) (not colon) Clean/ contaminated Colorectal surgery Deep incision 4–14% that (class II) Penetrating spontaneously abdominal trauma, dehisces or is Contaminated (Class III) large tissue injury, 3.4–13.2% opened by the enterotomy during surgeon (or bowel obstruction other Perforated designated Deep soft diverticulitis, clinician) DIRTY (Class IV) 3.1–12.8% Within 30 tissues of the Fever (>38C) necrotizing soft Deep because of or 90 days incision such tissue infections Incisional concern for of NHSN as the fascia Localized pain SSI deep SSI procedure and muscle or tenderness CLINICAL FEATURES AND DIAGNOSIS layers (+) organisms by The category of the SSI depends on the anatomy, or the culture or infected portion post-operatively non-culture based ○ Superficial incisional microbiologic SSI - infection involves the testing method skin and subcutaneous tissue Presence of at least 1 clinical ○ Deep incisional SSI - feature, in Deep soft tissue is involved absence of such as muscle and fascia microbiologic testing ○ Organ/Space SSI - Clinical Appropriate Organ/space is involved features clinical features specific for specific to the organ/space organ/space National Healthcare Safety Network categorized or SSI AND at least gave importance to the definition of SSI based on time one of the : to event, extent of tissue involvement, clinical features, Example: and criteria for diagnosis. Intra-abdomin Purulent CLASSIFICATIONS OF SSI al infection, at drainage from a Deeper than least 2 of the drain placed Extent of the Time to Clinical Criteria for : into the Tissue fascia/muscle event Features Diagnosis Within organ/space Involvement layers that Organ/ 30-90 days Fever (>38C) At least 1 clinical was opened Space SSI of NHSN (+) organisms feature AND at or procedure Hypotension from culture of least 1 of the manipulated Peri-incisional fluid or tissue following: during the pain or Nausea, obtained from a procedure Within 30 Skin tenderness vomiting superficial Superficial Purulent days of incision Incisional drainage from NHSN Subcutaneous Localized Abdominal SSI the superficial procedure tissue swelling, pain or Abscess or other incision erythema or tenderness evidence of heat infection (+) organisms by Elevated involving the culture (or transaminases organ/space non-culture detected on STUDY WELL & STAY HYDRATED! © MED TRANS  SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 4 Jaundice gross CT / Ultrasound guided percutaneous anatomical or drainage histopathologic Insertion of pigtail catheter will ensure examination complete evacuation of the abscess Catheter may be left for 1 or 2 weeks Radiographic imaging findings ANTIMICROBIAL THERAPY suggestive of Antibiotics are initiated: infection ○ Surrounding cellulitis NOTES: Associated with intact but indurated surgical Superficial Incisional SSI incision ○ There is now swelling, erythema, and even discharge Persistent cellulitis in the surrounding skin ○ Most of the time, when the site is touched for the after wound opening reason being it for drainage or discharge, there will Subcutaneous or deeper tissue has be tenderness persistent inflammation after debridement ○ When this is seen by the surgeon, removal of the or drainage suture will be attempted ○ Systemic signs of infection (SIRS) are present Deep Incisional SSI (Temperature ≥ 38℃, WBC ≥ 12) ○ Most of the patients under this category would be ○ Septic shock is persistent despite source control having implants, that’s why the length of time was Most common pathogens isolated extended to 90 days ○ S. aureus, coagulase-negative staphylococci, ○ There will be drainage near the site of incision Streptococcus spp., Enterococcus spp. Organ / Space SSI Empiric antibiotic therapy should be initiated ○ Systemic inflammatory response may be observed Empiric gram-negative therapy is often not necessary Antibiotics should be stopped with resolution of cellulitis GENERAL MANAGEMENT and normalization of leukocytosis Surgical management of the wound is a critical Guidelines: determinant of the propensity to develop an SSI ○ Short course (24 to 48 hours) - cellulitis that has E ective therapy for incisional SSIs consists solely of not improved with opening of the wound incision and drainage without the additional use of ○ Intra-abdominal organ/space infection - maybe antibiotics discontinued 4 days after source control. Antibiotic therapy is reserved for patient in whom Previous guidelines: 7 days evidence of significant cellulitis is present, or who Recently, they want to shorten the concurrently manifest a systemic inflammatory antibiotics to 4 days to prevent resistance. response syndrome E.g. In provinces, amoxicillin is still given and taken even if the symptom is just a WOUND EXPLORATION AND DEBRIDEMENT headache. Superficial SSI Antibiotic Prophylaxis ○ Performed in clinic, OPD, ER, or bedside ○ Administering antibiotics before performing ○ Remove surgical skin staples, sutures surgery to help decrease the risk of ○ Separate the wound edges post-operative infection. Evacuate any accumulated fluid or pus Cefazolin - drug of choice Evaluate integrity of fascial closure ○ But, we also use second-generation ○ Observe for signs of dehiscence cephalosporins such as: cefoxitin, cefuroxime, and Saline irrigation of the wound to remove cefotetan. loose devitalized tissue, exudate, and clots ○ The timing of prophylaxis will depend on the Use of NSS peak plasma concentration of the antibiotic of Deep SSI choice. ○ Problem: risk for fascial dehiscence E.g. Cefoxitin - peak plasma concentration of ○ Require emergency exploration must be in the 30 minutes. So, 30 minutes before the ER incision, antibiotic should be administered to If the fascia becomes infected, removal of the patient. After 30 minutes, incision should the sutures must be done start. ○ Debride deeper tissue, up to the muscle / fascial layer WOUND MANAGEMENT Facilitate abdominal exploration if subfascial In wound management, suture is removed and wound is infection is present exposed or opened. Then, letting it heal by secondary Organ / Space SSI intention, followed by serial dressing changes and ○ Diagnostic laparoscopy: non-invasive method for frequent wound packing removal, aims to decrease abscess evacuation microbial wound burden. Secondary Healing by Secondary Intention ○ Full thickness wound is allowed to close on its own. STUDY WELL & STAY HYDRATED! © MED TRANS  SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 5 It will undergo all the wound healing phases. intention (delayed primary closure maybe an Problem: there is a high inflammatory option). response forming a very large quantity of granulomatous tissue which can form: EDUCATIONAL CASE Abscess CASE Very large scar forming into the wound (keloid or hypertrophic scar) Patient education is a must in this type of healing since the wound of the patient can get infected if not taken care of. With this, delayed primary closure is recommended. Delayed Primary Closure and Reconstruction ○ Benefit: more rapid wound healing and less granulation tissue production. ○ E.g. Management of the patient starts with cleaning the wound and leaving it open or unsutured. Then, tell the patient to return after 5 57 female days. After 5 days, examine the wound in the Motor vehicular accident operating room, clean it, and examine again if Sustaining an avulsed lacerated wound on the there are revitalized tissues and contamination upper-eyelid right side, abrasions on the glabella and especially at the edges of the wound, then, nasal bridge remove it. Debride all possible necrotic tissues as well as evidence of infection or pus. Then, close or suture the wound. Wound is closed at a later date, but it is important to make sure that there’s no presence of infection. ○ A full thickness wound (up to the fascia) can still undergo delayed primary closure as long as its beneficial. E.g. Appendectomy - if there is presence of SSI, open the wound and then after a week, if there’s no infection, o er delayed primary closure. O ering delayed primary closure will depend on the assessment of the patient. 4 PHASES OF WOUND HEALING SUMMARY 1. HEMOSTASIS Surgical Site Infection (SSI) ○ Within seconds after injury, platelet ○ Infection related to a surgical procedure that aggregation occurs occurs near the surgical site within 30 days. ○ To stop bleeding Risk factors ○ This is the reason why the patient’s wound has no ○ Similar to those associated with impaired wound bleeding healing such as cigarette smoking, obesity, and 2. INFLAMMATION diabetes. ○ Cellular infiltration within 24 to 48 hours after Diagnosis and Treatment injury ○ Predominantly clinical ○ Polymorphonuclear cells are first infiltrating cells ○ Full evaluation includes examination of the skin, to enter the wound site surgical site, and documentation. ○ Increased vascular permeability, local ○ Assess whether there is systemic inflammatory prostaglandin release, and the presence of response. chemotactic substances Empiric Therapy 3. PROLIFERATION ○ Empiric antimicrobial therapy is directed at the ○ Roughly spans days 4 through 12 most likely organisms for a given wound site, ○ Tissue continuity is reestablished gram stain, wound class, prior antibiotics, and ○ Fibroblasts and endothelial cells infiltrate the antibiotic resistance patterns. healing wound Wound Care 4. MATURATION ○ Wounds that have been opened due to SSI are ○ Begins during the fibroblastic phase managed with serial debridement and dressing ○ Characterized by a reorganization of previously changes are often left to heal by secondary synthesized collagen STUDY WELL & STAY HYDRATED! © MED TRANS  SURGERY A LECTURE | DR. WINSTON S. VEQUILLA, MD 6 ○ Net shift toward collagen synthesis and ANTIMICROBIAL PROPHYLAXIS FOR PREVENT OF SSI reestablishment of extracellular matrix Antibiotic prophylaxis - administering antibiotics before performing surgery to help decrease the risk of PRIMARY SURVEY “ABCDE” postoperative infections (Should always be conducted) ○ Cefazolin Airway drug of choice for many procedures Breathing Most widely studied agent with proven Circulation e cacy Disability ○ Second-generation cephalosporins Exposure Cefoxitin Cefuroxime Cefotetan MANAGEMENT OF ACUTE WOUNDS (in order) 1. EXAMINATION SECONDARY HEALING/HEALING BY SECONDARY ○ Depth INTENTION Extent of the underlying structures injured Full-thickness is allowed to close and heal Can we close this wound in the ER or as an Inflammatory response is more intense outpatient? If it only took a few hours to Large quantity of granulomatous tissue is fabricated bring the patient to the ER then possibly ○ Configuration DELAYED PRIMARY WOUNDS What does the wound look like? Contaminated wounds ○ Nonviable tissue Wound is closed at a later date Will the tissue live or not? If not, may need to remove tissue SUMMARY 2. PREPARATION Definition - SSI is an infection related to a surgical ○ Anesthetic procedure that occurs near the surgical site WITHIN Lidocaine with or without epinephrine 30 DAYS OF SURGERY (under 90 days if an implant ○ Exploration was involved) To check for the underlying structures Risk factors - similar with those associated with poor involved wound healing and includes: ○ Cleansing ○ Cigarette smoking Pulsed irrigation - only saline is used to ○ Older age clean the site ○ Vascular disease ○ Hemostasis ○ Obesity If present, can underligate or do ○ Malnutrition cauterization ○ Diabetes ○ Debride nonviable tissue Diagnosis & treatment - Predominantly clinical, full ○ Betadine on surrounding skin evaluation includes examination of the skin ○ Antibiotics (rare) surrounding the surgical site with documentation of the ○ Tetanus presence and extent of erythema, edema or 3. APPROXIMATION induration, and any drainage ○ Deep layers Fascial layers only Absorbable suture BEST MOMENTS IN A DOCTOR’S LIFE ○ Superficial layers Cry of a newborn Can use absorbable sutures on dermal Waking up of a comatose patient. layer then eventually use non-absorbable The sound of restarting heartbeats when resuscitating a on epidermal layer depending on patient. SURGEONS’ PREFERENCE The genuine thank you of a patient relieved of pain/ Meticulous alignment stress/illness Nonabsorbable sutures on skin When someone randomly recognizes you in public and Staples thank you in front of your kids / family Monofilament When the poorest of the poor collect enough money, Dermal glues and gift you sweets for treating them free 4. FOLLOW-UP When anyone at work says take some rest now, you ○ (+) Cellulitis/drainage? have been working too much ○ Suture removal When someone says I want to become a Doctor like you. audentes Fortuna iuvat Q: What is the patient’s surgical wound classification (case)? Fortune favors the brave CONTAMINATED STUDY WELL & STAY HYDRATED! © MED TRANS