Surgical Site Infections SSI

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Surgical Site Infections (SSI)

• Yassar Youssef M.D.
• October 16th , 2007

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Intro

• 20 of admissions for SSTI
• Number 1 nosocomial infection in surgical
  patients
• Significant financial burden
• 7.3 days
• 3 K per patient

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Intro

• 100 contamination during surgery
• Bacteria present in every incision
• Bacteria ? Infection
• Variables?

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Inflammation and Bacteria

• Incision
• -release tissue factor -disrupt circulation
  -activate coag. protiens
  -Damage endothelium -exposed collagen -ADP
  release -plt aggregation
• Hemostasis Inflammation
• Vasodilation, ? permeability, edema

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Inflammation and Bacteria

• End products chemoattractant
• Coagulation cascade Precipitation of fibrin
  (natural dressing)
• Vasoactive phase followed by phagocytic one
• Neutrophils at 12 hrs
• mono at 1-2 days

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The skin incision promotes the delivery of host
defense elements to the surgical site before
contamination occurs, and fibrin provides a
biological dressing over the incised surface
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• If the chemoattractant is intense, what will
  happen?
• Bacteria within the fibrin!
• Is infection going to happen?

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Determinants of Infection

• Source of contamination
• Skin of patient (area of body)
• Airborne organisms
• Surgical team

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Determinants of Infection
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Bacteria

• Inoculum
• Inguinal hernia vs. Colectomy
• Virulence
• Cell wall, product and resistance

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Surgical site

• Hematoma
• Foreign bodies
• Dead tissue
• Dead space

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The Host

• Age
• Immune def.
• Hypoalbuminemia
• Hypoxemia
• Hyperglycemia
• Smoking

• Obesity
• Transfusion
• Malnutrition
• Hypothermia
• Existing infection

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Risk per wound class
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Laparoscopy

• Laparoscopic procedures, in particular
  laparoscopic cholecystectomy, have been
  associated with a decreased incisional infection
  rate compared with open cholecystectomy.
  Laparoscopy decreases the exposure of the
  incision to contaminating organisms and is
  associated with a decreased stress response and
  less tissue damage by desiccation or cautery.
• It has even been suggested that laparoscopic
  procedures should have one point subtracted from
  the NNIS risk index

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Wound infection SSI

• Superficial incisional
• Deep incisional
• Organ/Space SSI

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Superficial incisional
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Deep incisional
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Organ/Space SSI
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What can we do?

• Preoperative
• Intra-operative
• Postoperative

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Pre-op

• Open wounds
• Remote infection
• Smoking
• Bathing
• Laparoscopy
• Hair removal
• Antibiotics

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Most likely?
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Antibiotic Prophylaxis

• Safety
• Inexpensive
• Effective
• Timing

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Time of discontinuation (32,603)
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Deja Entendu

• 'This case was tough, let's give an antibiotic
  for 3 to 5 days'

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• C. diff

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When ?

• Contaminated
• Clean-contaminated?
• Clean?

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Microbiology of SSI
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GI
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Vascular
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Others
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Important !

• Antibiotics should not be given to cover
  indwelling drains or catheters, in
  lavage/irrigation fluid, or as a fail safe for
  poor surgical technique.

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OR

• Hygiene brief rinse with soap and water followed
  by alcohol gel
• Skin iodine, alcohol, and chlorhexidine
• Adhesive plastic drapes? No

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OR

• Gloves punctured 20
• Gowns protect for 2 hours!
• Mask? S. aureus carriers
• Hypothermia brief period ? risk

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OR Incision

• Tissues handled gently
• Minimize electrocautery
• Drains?
• Irrigation?
• Topical antibiotics?
• Closure of contaminated or dirty wounds?
• Lacking good quality studies
• Data are mixed

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Post-op

• Transfusion
• Euglycemia
• Nutrition
• Oxygenation

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Conclusions

• SSI are common
• Preventable
• Antibiotics prophylaxis
• Early diagnosis and treatment