SURGICAL SITE INFECTIONS:

PRINCIPLES OF MANAGEMENT

PRESENTED BY DR OTU
 OUTLINE
• INTRODUCTION
• CLASSIFICATION OF SURGICAL SITE INFECTION
• PATHOGENESIS
• RISK FACTOR
• CLINICAL PRESENTATION
• INVESTIGATIONS
• TREATMENT MODALITIES
• COMPLICATIONS
• PREVENTION
• CONCLUSION
 INTRODUCTION
• SSI are Infections that occur as a complication of surgery within 30 days of
operation or one year in a procedure which involves use of inplant

• SSIs result from wound contamination mainly which could be from either
endogenous microflora such skin flora inoculated during surgery (S
epidimidis, S aureus, Enterococcus) or Exogenous (surgical, hospital
personel,intraoperative circumstance such as trafic, equipment and air )

• Microbiology varies depending on the types of procedures performed and

body region operated upon
• Table 4.7 SSI rates relating to wound contamination
• Type of surgery Infection rate (%) Rate before prophylaxis
• Clean (no viscus opened) 1–2 The same
• Clean-contaminated (viscus opened, minimal spillage) < 10 Gastric
surgery up to 30%
• Biliary surgery up to 20%
• Contaminated (open viscus with spillage or inflammatory disease) 15–20
Variable but up to 60%
• Dirty (pus or perforation, or incision through an abscess) < 40 Up to 60%
or more
 SURGICAL WOUND CLASSIFICATIO

• Class I/Clean: An uninfected operative wound in which no

inflammation is encountered, lumen is not entered. In addition, clean
wounds are primarily closed and, drained with closed drainage. no
break in aseptic technique. risk of infection is 1-2%
• Class II/Clean-Contaminated: An operative wound in which the body
lumen are entered under controlled conditions and without unusual
contamination. eg operations involving the biliary tract, appendix,
vagina, and oropharynx, provided no evidence of infection or major
break in technique is encountered. Risk of infection is 10 - 15%
SURGICAL WOUND CLASSIFICATION

Class III/Contaminated: Open, fresh, accidental wounds, operations

with major breaks in sterile technique (e.g., open cardiac massage) or
gross spillage from the gastrointestinal tract, and incisions in which
acute, nonpurulent inflammation is encountered are included, Risk of
infection is 10-20%
• Class IV/Dirty-Infected: Old traumatic wounds, and those that involve
existing clinical infection or perforated viscera. This definition
suggests that the organisms causing postoperative infection were
present in the operative field before the operation. Risk of infection is
greater than 50%
CLASSIFICATION BASE ON SEVERITY
• This is the infection of the skin wound
• Grade 1 Induration of the wound beyond what is expected for that period in
the wound haling process
• Grade 2 stitch abscess
• Grade 3 Discharge of purulnt material from part of the wound
• Grade 4 Discharge of purulent material from the whole wound
 ANATOMICAL CLASSIFICATION OF SURGICAL SITE
INFECTION
INCISIONAL ORGAN/SPACE
SUPERFICIAL DEEP
DURATION < 30 DAYS <30 DAYS <30 DAYS
< 1 YEAR (IMPLANT SURGERY) <1 YEAR (IMPLANT SURGERY)
INVOLVEMENT SKIN MUSCLE ORGANS
SUBCUTANEOUS TISSUE FASCIA POTENTIAL/ACTUAL
CAVITY( PLEURAL,PERICARDIA
L,ABDOMINAL)

DEFINING CRITERIA (AT LEAST 1. PURULENT DISCHARGE 1. PURULENT DRAINAGE 1. PURULENT DISCHARGE
ONE) 2. ISOLATION OF ORGANISM 2. SPONTANEOUS/ FROM DRAIN
3. LOCAL FEATURES OF DELIBERATE WOUND 2. ISOLATION OF ORGANISM
INFECTION DEHISCENCE +SYSTEMIC 3. ABSCESS COLLECTION
4. SURGEON/ATTENDING OR LOCAL FEATURE OF 4. SURGEON/ATTENDING
PHYSICIAN’S DIAGNOSIS INFECTION PHYSICIAN’S DIAGNOSIS
3. ABSCESS COLLECTION
4. SURGEON/ATTENDING
PHYSICIAN’S DIAGNOSIS
SCHEMATIC REPRESENTATION
CLASSIFICATION
SOUTHAMPTON GRADING SYSTEM

• 0 Normal healing • 3 Clear or haemoserous discharge

• 1 Normal healing with mild bruising 3a at one point (less or equal 2cm)
or erythema 3b along wound (greater than
1a some bruising 2cm)
1b considerable bruising 3c large volume
1c mild erythema 3d prolong (greater 3/7)
• 2 Erythema with other signs of • 4 Pus
inflammation 4a at one point (less or equal2cm
2a at one point 4b along wound (greater than
2cm))
2b around sutures
• 5 Deep or sevre wound infection
2c along wound
2d around wound
ASEPSIS WOUND SCORE
• A - Additional treatment ; Antibiotics for wound infection 10
Drainage of pus under L. A 5
Debridement of wound under G.A 10
• S - Serous discharge daily 0-5
• E - Erythema daily 0-5
• P - Purulent exudate daily 0-10
• S - Separation of deep tissue daily 0-10
• I - Isolation of bacteria from wound 10
• S - Stay as in-patient prolonged over 14/7 as a rsult of wound infection
 PATHOGENESIS

•Staphylococcus aureus and Escherichia coli remain the most frequently

isolated pathogens. An increasing proportion of SSIs are caused by
antimicrobial-resistant pathogens, such as methicillin-resistant S.
aureus (MRSA)
• Microbial contamination of the surgical site is a necessary precursor
of SSI. The risk of SSI can be conceptualized according to the following
relationship
• Dose of bacterial X contamination virulence = Risk of surgical site infection
Resistance of the host patient
PATHOGENESIS
Quantitatively, it has been shown that if a surgical site is contaminated
with >105 microorganisms per gram of tissue, the risk of SSI is markedly
increased.

Microorganisms may contain or produce toxins and other substances that

increase their ability to invade a host, produce damage within the host, or
survive on or in host tissue. For example, many gram-negative bacteria
produce
endotoxin, which stimulates cytokine production. In turn, cytokines can
trigger the systemic inflammatory response syndrome that sometimes
leads to multiple system organ failure
 RISK FACTORS

• In the context of SSI pathophysiology, strictly refers to a variable that has a

significant association with the development of SSI after a specific operation
a. Diabetes
b. Nicotine use
c. Steroid use
d. Malnutrition
e. Prolonged preoperative hospital stay
. f Preoperative nares colonization with Staphylococcus aureus
g. Perioperative transfusion
 CLINICAL PRESENTATION
HISTORY
• Age of patient
• Type of surgery (Open vs Laparoscopic;Emergency vs Elective)
• Intraoperative details ( duration of surgery, use of prophylactic antibiotics,
degree of intra-operative soilage,presence of suppuration,type of wound
closure)
• Duration from time of surgery
• Presence of co-morbidities( Immunosuppression,Diabetic, ,malignancy,
malnutrition)
• Smoking
• Medications e.g chronic steroid use, NSAIDs
 CLINICAL PRESENTATION
PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINATION
• Acutely ill looking
• Cachectic
• Altered sensorium/delirium
• Pale
• Icteric
• Dehydrated
• Febrile
• Significant Regional Lymphadenopathy
• Anthropometric parameters
 CLINICAL PRESENTATION
GENERAL PHYSICAL EXAMINATION
Surgical wound examination may reveal;
• Undue surgical site tenderness
• Local spreading erythema
• Local oedema/Induration
• Differential warmth
• Cutaneous crepitus, vesicles and bullae
• Active wound discharge
(quantity,colour,odour)
• Wound dehiscence
• Surrounding Cellulitis
• Surrounding skin(pigmentation,scarring)
 CLINICAL PRESENTATION
RESPIRATORY SYSTEM ABDOMEN
• Dyspneic,tachypneic • Abdominal distention
(symetrical/asymmetrical)
• Chest wall asymmetry
• Local signs of abdominal wound
• Dull/stony dull percussion note infection , erythema, persistent
• Reduced air entry tenderness, induration, purulent
discharge,wound dehiscence,
evisceration
CARDIOVASCULAR SYSTEM
• Absence of bowel sounds
• Tachycardic
• PR- tender boggy
• Hypotension rectovesical/rectovaginal pouch
 INVESTIGATIONS
• Wound Swab/ Aspirate M/C/S
• FBC with differential WBC count, Erythrocyte Sedimentation Rate
• Serum Protein ,Albumin, Pre –albumin(<16g/dl)
• Serology ( HbsAg, anti-HCV, RVS)
• Fasting Plasma Glucose
• Urinalysis
• Plain Radiography( chest PA, Abdominal Xray Erect/supine/left lateral)
• Abdominopelvic Ultrasound scan
• CT Scan or MRI ( brain and thoracic abscess) – contrast enhanced
• LFTs, ABG and Blood culture/Urine culture
• E/U/Cr
• Grouping and cross-matching
 TREATMENT MODALITIES
Depends on severity of infection;
• Depth of infection
• Systemic involvement

• May be multi-disciplinary

Treatment approach could be;

• Non-operative
• Operative
Surgical debridement
Operative infection source control
Re-exploration
 TREATMENT OF INCISIONAL SSIs
SUPERFICIAL INCISIONAL SSI
• Does not require hospital admission

• Removal of staples or stitches is done if there is suppuration

• Wound edges expressed for possibility of wound discharges

• Wound swab is done

• Surgical wound is cleansed/irrigated with physiologic saline solution
• Sterile wound dressing change done daily

• Frequency of wound dressing depends on state of wound (presence of healthy granulation tissue)
 TREATMENT OF INCISIONAL SSIs
SUPERFICIAL INCISIONAL SSI
• therapeutic course of empirical antibiotics
• Inspection of wound during dressings for improvement
• Tetanus prophylaxis – required if individual is not up to date or unsure
- I.M Tetanus toxoid 0.5ml stat
- SC ATS 1500IU Stat

• Definite wound closure ( Secondary wound closure or secondary intention)

 TREATMENT OF INCISIONAL SSIs
DEEP INCISIONAL SSI
• Does not require hospital admission if no systemic involvement

• Removal of alternate stitches/staples initially around discharging wound site

( if discharge is present)

• Care of the infected wound would include;

• Reduction of wound bio-burden( cleansing/irrigation, debridement,de-sloughing, topical antimicrobial use)
• Exudate management
• Peri-wound care
 TREATMENT OF DEEP INCISIONAL SSIs
SURGICAL DEBRIDEMENT
• Involves use of sharp dissection (one time or sequential)

• Indicated in presence of extensive necrotic tissue/slough

• Patient preparation for debridement
• Adequate resuscitation
• Commence broad spectrum antibiotics
• Obtain informed consent
 TREATMENT OF DEEP INCISIONAL
PROCEDURE
SSIs

• Start debridement from base of wound (Be generous while debriding tissues)

• Remove foreign bodies, fragments of dressing materials

• Continue debridement until red bleeding margins are seen
• Irrigate area with normal saline and bactericidal agent
 TREATMENT OF DEEP INCISIONAL
SSIs
WOUND IRRIGATION
• Continuous normal saline wound irrigation is done per dressing as well as after
every wound inspection
• Low to intermediate irrigation pressure of 4 to 15 psi (8 psi)
• All wound surfaces are irrigated which may require opening wound edges and
flaps for exposure
• Irrigation fluid opened longer than 24 hrs should be discarded
• Patient should be positioned such that solution runs from the upper end of
the wound downward
 TREATMENT OF DEEP INCISIONAL SSI
WOUND IRRIGATION
• Irrigation is performed using strict aseptic technique

• Soiled dressings are removed and discarded

• Clean peri-wound area with normal saline and wipe intact skin with skin
protectant wipe

• Work from cleanest to most contaminated part of wound

• Patient should be positioned comfortably to allow further drainage

 TREATMENT OF DEEP INCISIONAL
Wound cleansing agents;
SSI
• Chlorhexidine

• Iodine-based agents (povidone-iodine, cadexomer iodine)

• Silver –based agents ( silver sulfadiazine)

• sodium hypochlorite(Eusol)

• Hydrogen peroxide

• Salt dips(Sitz bath)

 TREATMENT OF DEEP
INCISIONAL SSIs
WOUND DRESSINGS
• Wound is packed with Saline moistened sterile gauze packs ( offers a
debridement property)

• Honey wound dressing could be used for necrotic or deep wounds requiring
extensive granulation tissue
 TREATMENT OF DEEP INCISIONAL
SSIs
• Wound examination done during dressings taking note of wound
characteristics size, edges, discharge ( type, colour, quantity, nature, odour),
presence of healthy granulation tissue.

• With good granulation tissue and optimal wound contraction, definitive closure
is planned

• Wound closure could be achieved via delayed primary closure, secondary

closure or healing by secondary intention( depending on presence of healthy
granulation tissue)
 TREATMENT OF DEEP INCISIONAL
SSIs
ANALGESIA
• Adequate pain management should be ensured
• Moistening of dressings before removal to reduce pain
• Use of 2% topical lidocaine gel
• Oral use of systemic analgesics based on severity of pain using the WHO
analgesic pain ladder
• Use of Non-opioid e.g Tabs Acetaminophen 10-15mg/kg/dose 8hrly
• NSAIDs
• Weak Opioids e.g Dihydrocodeine 30mg TDS, Tramadol 50mg 12hrly
• Strong Opioids e.g Fentanyl or morphine preparations (0.1mg/kg and titrated
up as required)
 TREATMENT OF ORGAN/SPACE INFECTIONS

RESUSCITATION
• Indicated in cases of deep Organ/Space SSIs

• Two large bore IV setup done and fluid resuscitation commenced

• 2L Bolus of Ringers lactate is recommended titrated based on clinical response

• Aim is to ensure MAP >65mmHg, CVP > 12mmHg

• IV Dopamine or Noradrenaline are given if MAP <65mmHg

• Urethral Catheterisation for Hourly urinary output
 TREATMENT OF ORGAN/SPACE
SSI
RESUSCITATION
• Intra nasal Oxygen supplementation for ventilatory support delivered via an
Oxygen mask at about 4 -5 l/min ( sPo2 at >94%)
• Blood transfusion is done to ensure PCV > 30%
• Commencement of IV Empirical Broad spectrum Antibiotics e.g IV
Ceftriaxone/Sulbactam 1.5g stat then 12hrly, I V Amoxicillin/Clavulanate 1.2 g
stat then 12hrly in combination with Metronidazole IV 500mg 8hrly
• Definitive Antibiotics is subsequently introduced based result of aspirate
M/C/S
• IV Vitamin C 100mg 8hrly for 48 to 72 hrs
 TREATMENT OF ORGAN/SPACE SSI
NUTRITIONAL SUPPORT
• Established once malnutrition is identified ( clinically via significant weight
loss,weakness, anaemia, oedema of hypoproteinemia, biochemically serum
albumin < 3.5g/dl)
• Routes : Enteral(sip feeding) and parenteral
• Enteral nutrition could be via use of oral supplements e.g ensure,sustagen or
tube feedings e.g Blenderised diet, Polymeric ( Isocal ,osmolyte), monomeric
(vivonex TEN), disease specific( aminaid, hepatic aid)
• Supplemental IV Aminoacid is administered at a rate of 1g/kg/day
 TREATMENT OF ORGAN/SPACE SSIs
• Source control of wound infection is required in treating organ/space
infections

• This may be achieved via percutaneous image guided drainage or surgical re -

exploration
 TREATMENT OF ORGAN/SPACE SSIs
PERCUTANEOUS INTRA ABDOMINAL ABSCESS DRAINAGE
• CT-Guided catheter drainage- gold standard treatment of most intra-
abdominal abscesses
• CT- guided drainage delineates the abscess cavity
• A diagnostic needle aspiration is initially performed to confirm presensce of
pus
• A large-bore drainage catheter is subsequently placed in the most dependent
position
 TREATMENT OF ORGAN/SPACE SSIs
PERCUTANEOUS ABSCESS DRAINAGE
• Clinical improvement is expected in 48 to 72hrs post drainage( else Repeat CT
Scan)

• Surgical drainage becomes mandatory if residual fluid cannot be evacuated

with catheter irrigation, manipulation or additional drain placement

• Criteria for removal of percutaneous catheters;

• Resolution of sepsis
• Minimal drainage from catheter
• Radiologic evidence of abscess resolution(USS or CT)
 TREATMENT OF ORGAN/SPACE SSIs
BURST ABDOMEN/EVISCERATION
• Resuscitation and patient optimisation
• IVF fluids at maintenance 3L /day ( 2L of 5% D/S,1L N/S) with deficit fluid
correction as appropriate titrated to clinical response
• Nasogastric tube aspiration for gastric decompression
• Urethral catheterisation for hourly urinary output( 0.5 to 1ml/kg/hr)
• Nutritional Supplementation instituted
• IV Antibiotics Broad-spectrum ( IV Tandak 1.5g 12hrly,IV Metronidazole)
• Blood transfusion to ensure pre-operative PCV is at least 30 %
• Exposed viscera is covered with warm-saline moistened gauze dressing and
patient worked up for emergency re-exploration/closure(retention stitiches)
 COMPLICATIONS
• Wound dehiscense/Burst Abdomen
• Abscess collections
• Cellulitis/Necrotizing Fascitis
• Sepsis Syndrome
• Poor Scars ( Hypertrophic, Keloid)
• Unstable scars
• Dyschromic scars
• Chronic ulcers/ Marjolins
• Joint contractures
• Incisional hernias
 PREVENTION OF SSI
PRE-OPERATIVE
• Heavy smokers encouraged to stop smoking at least 30 days before surgery
• Plasma glucose optimization in diabetics
• Nutritional support for 1 to 2 weeks pre-operative
• Weaning patients off steroid pre-op
• Bowel preparation
• Antiseptic showering
• antibiotic prophylaxis
 PREVENTION OF SSI

• Preoperative hair removal

• . Preoperative hand/forearm antisepsis/ scrubbing
• Patient skin preparation in the operating room
• minimize personnel traffic during operations.
• Conventional sterilization of surgical instruments
• Operating room environment: Ventilation
• Surgical attire and drapes which includes scrub suits, caps/hoods,
shoe covers, masks, gloves, and gowns.
 PREVENTION OF SSI
INTRA-OPEARTIVE
• Asepsis tecnique

• Surgical technique
Excellent surgical technique is widely believed to reduce the risk of SSI.
Such techniques include maintaining effective hemostasis while
preserving adequate blood supply, preventing hypothermia, gently
handling tissues, avoiding inadvertent entries into a hollow viscus,
removing devitalized
 PREVENTION OF SSI
• Staff wearing non-sterile theatre wear should keep their movements in and
out of the operating area to a minimum

• The operating team should remove hand jewellery before operations.

• The operating team should remove artificial nails and nail polish before
operation
 PREVENTION OF SSI
• If diathermy is to be used, ensure evaporation to dry antiseptic skin
preparations and avoid pooling of alcohol-based preparations

• When using sutures, consider using antimicrobial triclosan-coated sutures,

especially for paediatric surgery, to reduce the risk of surgical site infection.

• Consider using sutures rather than staples to close the skin to reduce the risk
of superficial wound dehiscence.
 PREVENTION OF SSI
POST-OPERATIVE

• appropriate interactive dressing at the end of the operation.

• Use an aseptic non-touch technique for changing or removing surgical wound

dressings

• Use sterile saline for wound cleansing up to 48 hours after surgery.

• Advise patients that they may shower safely 48 hours after surgery.
• Adequate Discharge planning on wound care
 CONCLUSION
• Despite Various measures, SSI still accounts for post-operative
significant morbidity and mortality

• Risk assessment, early identification and institution of appropriate

treatment mitigates morbidity burden
 REFERENCES
• Garner JS. CDC guideline for prevention of surgical wound infections,1985.
Supercedes guideline for prevention of surgical wound infections published in
1982. (Originally published in 1995). Revised. Infection Control 1986;7(3):193-200
• Simmons BP. Guideline for prevention of surgical wound infections. Infection
Control 1982;3:185-196.
• Garner JS. The CDC Hospital Infection Control Practices Advisory Committee. AmJ
Infect Control 1993;21:160-2
• Shwartz’s Principles of Surgery, 10th Edition
• Sabiston Textbook of Surgery. The Biological Basis of Modern Surgical Practice,
19th Edition
• BAJA’S Principles and Practice of Surgery including pathology in the tropics, 5th
Edition