surgical site infection What is surgical site infection? Discuss the methods to reduce - PowerPoint Presentation

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surgical site infection

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What is surgical site infection? Discuss the methods to reduce surgical site infection.

Enumerate the factors responsible for surgical site infection.

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Nosocomial Infection

An infection acquired in hospital by a patient who was admitted for a reason other than that infection .

Infections occurring for more than 48 hours after admission are usually considered nosocomial

Amongst surgical patients, SSI are the most common nosocomial infections

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Classes of SSI

Superficial incisional SSI:

Infection occurs within 30 days after the operation and infection involves only skin of subcutaneous tissue of the incision

and at least one of the following:

–1–Purulent drainage with or without laboratory confirmation from the superficial incision

–2–Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision

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–3–At least one of the following signs or symptoms of infection:

--Pain or tenderness

--

Localised

swelling

--Redness

--Heat

--And superficial incision deliberately opened by a surgeon, unless incision is culture negative

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Deep incisional SSI:

Infection occurs within 30 days after the operation if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operation and infection involves deep soft tissues (e.g.

fascial

and muscle layers) of the incision and at least one of the following:

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–1–Purulent drainage from the deep incision but not from the organ/space component of the surgical site

–2–A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms:

--Fever (>38°C)

--Localized pain

--Tenderness unless site is culture-negative

–3–An abscess or other evidence of infection involving the deep incision is found on direct examination, during re-operation or by

histopathological

or radiological examination

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Organ/space SSI:

Infection occurs within 30 days after the operation if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operation and infection involves any part of the anatomy (e.g. organs or spaces), other than the incision, which was opened or manipulated during an operation and at least one of the following:

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–1–Purulent discharge from a drain that is placed through a stab wound into the organ/ space

–2–Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space

–3–An abscess or other evidence of infection involving the organ/space that is found on direct examination, during re-operation, or by

histopathologic

or radiological examination

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Strategies to prevent SSI

Objectives

1-Reduce the inoculum of bacteria at the surgical site

2-Surgical site preparation

3-Antibiotic prophylaxis strategies

4-Optimize the microenvironment of the surgical site

5-Enhance the physiology of the host (host defenses)

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risk factors of SSI classified as:

1-Patient-related (intrinsic)

2-Preoperative

3-Operative

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Patient-related factors

a-

Diabetes

—recommendation Preoperative Control serum blood glucose—reduce HbA1C levels to <7% before surgery if possible

Maintain the postoperative blood glucose level at less than 200 mg/

dL

b-Smoking, anemia, malnutrition

c-

Hypoalbuminemia

, jaundice

d-Obesity, hyperlipidemia

e-Ascites, PVD

f-

Immunosupression

.

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2-Procedure-related risk factors

a-

Hair removal technique (clipping> on table shaving > previous night shaving)

b-Preoperative infections control and bath

c-Surgical scrub

d-Skin preparation

e-Antimicrobial prophylaxis

f-Surgeon skill/technique/instruments

g-Asepsis

h-Operative time (should be within 1.5 times the normal)

j-Operating room characteristics/OT sterility.

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Surgeon skill and technique

Excellent surgical technique reduces the risk of SSI

Includes

a-Gentle traction and handling of tissues

b-Effective hemostasis

c-Removal of devitalized tissues

d-Obliteration of dead spaces

e-Irrigation of tissues with saline during long procedures

f-Use of fine,

nonabsorbed

monofilament suture material

h-Wound closure without tension.

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Cellulitis

Cellulitis

is a common infection of skin and subcutaneous

tissues, most frequently caused by

Streptococcus

pyogenes

and occasionally Staphylococcus species. Infection

occurs after the skin is breached (e.g. insect bite,

scratching, skin rash, minor trauma).

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Cellulitis may

seem to occur spontaneously, although careful inspection

reveals a break in the skin After subcutaneous inoculation,

streptococci release toxins which permit rapid spread

of organisms. The acute inflammatory response results

in the clinical features of warmth, pain and tenderness,

erythema, and

oedema

. Severe cellulitis may progress

to suppuration and skin necrosis.

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Differential diagnosis includes other causes of limb

swelling, deep venous thrombosis, rupture of a Baker’s

cyst, calf

haematoma

and

erythematous

skin conditions.

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excretion of penicillin. Erythromycin or

a third generation

cephalosporin is used in patients with penicillin

allergy. Any predisposing cause (e.g.

tinea

pedis

) is

treated vigorously. If

cellulitis

does not resolve rapidly,

the antibiotic is increased or changed.

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Lymphangitis

Lymphangitis

is associated with bacterial infections of

extremities where the inflamed lymphatic vessels appear

as several thin, red, tender lines on the slightly

oedematous

skin progressing towards the regional

lymph nodes which are enlarged and tender (lymphadenitis).

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Cellulitis

of an extremity is treated by elevation and

immobilisation

with a splint or plaster ‘back slab’, and

antibiotics. Penicillin (2 million units every 6 hours)

or

flucloxacillin

(1–2 g every 6 hours) is given intravenously

for 3–5 days and then continued orally

for a further 10 days. Blood levels of penicillin may

be increased by oral

probenecid

, which reduces renal

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Lymphangitis

usually is caused by streptococci

and staphylococci. Chemical

lymphangitis

may

result from

irritative

compounds used for lymphangiography.

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Treatment is the same as for

cellulitis

, consisting

of rest and elevation of the extremity and antibiotics.

Rarely,

suppurative

regional lymph nodes require surgical

drainage.

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Folliculitis

, furuncles and carbuncles

‘

Folliculitis

’ refers to infection with pus formation

within a hair follicle and is limited to the dermis. It

may be extensive if many follicles are infected over a

wide area, such as the face.

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A ‘furuncle’ is infection of a small number of hair

follicles within a small confined area. A ‘carbuncle’ is

an abscess involving a number of adjacent hair follicles

where the infection has penetrated through the dermis

and formed a

multiloculated

subcutaneous abscess between

the fibrous septa which anchor the skin to the

deep fascia

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Furuncles and carbuncles occur most frequently

on the back of the neck, lower scalp, and the torso. Abscesses on the upper part of the body are usually

caused by staphylococci, while infections below

the umbilicus are due largely to aerobic and anaerobic

coliform

organisms.

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Local hygiene is usually sufficient to treat

folliculitis

,

although antibiotics are required for extensive infections.

Furuncles and carbuncles require incision and

drainage. Fibrous tissue septa must be broken down

so that all pockets of pus can be drained completely.

Antibiotics are indicated for severe and spreading infections,

and in

immunocompromised

patients.

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Hidradenitis

suppurativa

Hidradenitis

suppurativa

refers to infection of

apocrine

sweat glands, and occurs in the

axillae

, around the external

genitalia, and the inguinal and

perianal

regions

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Apocrine

sweat glands have tortuous

secretory

ducts within the skin and produce thick

secretions, and infection occurs when ducts become

blocked, most commonly during excessive glandular

activity at

adolescence.Staphylococci

or

Gramnegative

bacilli and anaerobes are causative organisms.

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Patients present with multiple small but painful

abscesses and sinuses, often bilaterally. Repeated or

long-standing infection results in considerable scarring,

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Antibiotic therapy alone is

often inadequate, although long-term antibiotic therapy

may be useful in suppressing acute infections. Abscesses

require incision and drainage. Excision of the

affected hair-bearing area and the subcutaneous fat

usually is required, and results in good symptomatic

relief.

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Synergistic gangrene

‘Synergistic gangrene’ refers to a group of soft tissue

infections

characterised

by tissue necrosis and caused by several

species of microorganisms acting synergistically. Previous

nomenclature (

necrotising

fasciitis,

necrotising

erysipelas,

Meleney’s

gangrene, Fournier’s gangrene,

non-

clostridial

gangrenous

cellulitis

)

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Clinical features

Synergistic gangrene is caused by micro-

aerophilic

streptococci acting synergistically with aerobic staphylococci,

with or without Gram-negative bacilli. It usually

occurs in debilitated patients with other disorders

(e.g. diabetes, malnutrition, alcoholism, liver disease,

renal

failure

,

malignant

disease

, immune compromise).

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Synergistic gangrene presents initially as cellulitis

with severe pain which is out of keeping with the minor

local clinical signs but consistent with the seriousness

of the condition. Infection spreads rapidly along

fascial

and subcutaneous planes without a severe inflammatory reaction.

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Bacterial toxins cause tissue and skin

necrosis. Crepitus occurs when gas-forming organisms

are present. Signs of systemic sepsis and

toxaemia

occur

quickly.

‘Fournier’s gangrene’ is the name given to synergistic gangrene involving the perineum and scrotum. It

may be extensive and involve the abdominal wall and

buttocks, and is a rare complication of

anorectal

and

perineal

surgery, trauma or minor infection.

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Treatment

Synergistic gangrene must be treated urgently by

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Select the single correct answer to each question.

1:Cellulitis:

a-is occasionally caused by Gram-negative coliforms

b-often occurs spontaneously without any apparent

cause or organism

c- is treated with rest,

immobilisation

and high-dose

penicillin

d-frequently requires surgical drainage

e-is often complicated by suppuration and skin necrosis

2:Fournier’s gangrene:

a-is a form of

pyomyositis

b-occurs mainly in debilitated patients and can be

life-threatening

c -is usually due to

stapylococcal

infection

d-can be treated by hyperbaric oxygen alone

e-is seldom managed surgically