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DR BASHIRU AMINU
y Introduction y Definition y Historical perspective y Epidemiology y pathogenesis y aetiology y Classification y Clinical features y Management y conclusion
y Surgical site infections continue to be a major
challenge y in spite of various advances in science y It is responsible for significant increase in mortality , morbidity &hospital stay y This means more expenditure
definitions y Infection occurring at site of operation or surgical tract within thirty days of surgery or one year ff implant surgerys .
Historical perspective y Edwin smith(circa 1600 bc). ebers papyrus(circa 1534) y Hippocrates (460ad-377bc) y Galen laudable pus theory .
14th century at the time of ambrose pare(1510-1590) y Koch (1843-1910) recognized septic foci as result of microbial growth y Semmelweis(1818-1865) reduction in puerperal sepsis .
y Pasteur revolutionarized concept of wound infection y Lister(1827-1912) used carbolic acid y Antoine depagne(1862-1925) reintroduced debridment & delayed closure y Alexander fleming(1881-1955)of penicillin .
bloodgood made it routine use .y Halsted introduced rubber gloves to his scrub nurse who allergic to materials used in sterilizing instruments y His student J.
shows rates of 10% costing1 billion pounds annually. y The 2002 report (NINSS) Oct 97 and Sept 2001.epidemiology y frequency of SSI difficult to monitor y A survey by WHO infections varying from 3-21%. . with wound infections accounting for 5-34% of the total.
y 75% of deaths in surgical patients is related to SSI y Actual estimates difficult to make here due to paucity of data .
complement proteins . Mast cells .pathogenesis y With incision on skin 5 critical initiators of y y y y y inflammatory response are activated Coagulation proteins platelets part of the hemostatic mechanism herald the onset of inflammation.
y bradykinin is produced from protein precursors. y The net effect of 5 factors is vasodilation and increased blood flow .
etc . monocyte.y products from 5 initiators result in nonspecific chemoattractant signals. y mast cells produce specific chemokine signals that "draw" specific neutrophil.
y The point is that tissue injury initiates mobilization of phagocytes into the wound before contamination occurs .
infection does not develop because host defenses are efficient y A complex interplay between host. microbial. y Factors that affect surgical wound healing are classified below .aetiology y All surgical wounds are contaminated y most cases. and surgical factors y ultimately determines prevention or establishment infection.
y the dose of inoculum.microbiology y Microbial factors are. y virulence. y Microenvironment y impaired host defenses y patient's own endogenous flora .
y The traditional microbial concentration is bacterial counts higher than 10. .000 organisms per gram of tissue (or in the case of burned sites. organisms per cm2 of wound).
and 1010 1012 bacteria/g of stool in the rectosigmoid colon.y largest inoculum is structure ordinarily heavily colonized eg bowel. y distal small intestine and colon have large concn of bacteria with 103 . y 105 .104 bacteria/mL of distal small bowel content.106 bacteria/mL in the right colon. .
y Significant concn in biliary tract when patients are over 70 years of age y or have obstructive jaundice etc .y Large amts also present in stomach of older patients with hypo.or achlorhydria.
y Procedures in female genital tract will encounter 106 . or urinary tract have significant contaminants y Notably.107 bacteria/mL. y Procedures in oropharynx. lung. SSIs are generally consequence of intra operative contamination .
y The most bacteria responsible for SSIs Staphylococcus aureus. y The emergence of resistant strains considerably increased burden of morbidity and mortality .
g+s.y skin and mucosal surfaces . y Contaminants in GIT surgery are bowel flora y which include g-ve bacilli (eg. enterococci . E coli). gram-positive cocci (notably staphylococci) y G-ve aerobes and anaerobic bacteria contaminate skin in the groin/perineal areas.
.y G+ particularly staph & strep are main exogenous flora in SSIs. operating room air. y surgical/hospital personnel y intra operative circumstances. y Sources of such pathogens include . instruments.
y this way.body of individual without causing sickness. it can be passed on to other individuals .y Methicillin resistant Staphylococcus aureus (MRSA) y MRSA colonize skin .
y Immuno suppressants.y Systemic factors include. diabetes. poor tissue perfusion y obesity. hypovolemia. steroids. malnutrition. . y age.
.y Wound characteristics include. y dead space. y nonviable tissue in wound. hematoma. y foreign material. including drains and sutures. poor skin prep +shaving y and preexistent sepsis (local or distant).
. y intraoperative contamination.y Operative chrxs include poor surgical technique. y lengthy operation (>2 h). eg theater staff and instruments y inadequate theater ventilation.
y The type of procedure is a risk factor. .y prolonged preop stay y hypothermia.
Vacuum-assisted wound closure .
classification y Various classifications y traditional developed in wake of uv light study of 1964 y Primarily to provide clinical estimate of inoculum of bacteria y does not take into cognisance factors like. y virulence. host defences. microenvironment of the wound .
y Clean Wounds y does not enter into a colonized viscus or lumen y eg elective inguinal hernia repair y SSI risk is minimal y common pathogen is Staphylococcus aureus y SSI rates is 2% or less .
y Clean-Contaminated Wounds y enters colonized viscus or cavity under elective y contaminants are endogenous bacteria y Eg sigmoid colectomy wounds contain E coli and Bacteroides fragilis .
pulmonary resection.y Elective intestinal resection. and head-neck cancer op in oropharynx are examples y Infection rates in the range of 4% to 10% . gynecologic procedures.
y Contaminated Wounds y gross contamination present in absence of obvious infection. y eg laparotomy for penetrating injury +intestinal spillage y contaminants bacteria introduced by gross soilage y Infection rates greater than 10% .
y Dirty Wounds y active infection is already present y Abdominal exploration for acute bacterial peritonitis and intra-abdominal abscess are examples y Pathogens those of active infection y Unusual pathogens are seen y Esp if infection occurred in hospital or nursing home setting .
y US CDC developed the NNIS Risk Index system y member hospitals report cumulative data. y This simplified risk index has a range from 0 to 3 points. y A point is added to the patient's risk index for each of the following 3 variables: . y A risk index developed to include . y traditional wound classification system defined above and additional variables.
y A point is added to the patient's risk index for each of the following 3 variables .y This simplified risk index has a range from 0 to 3 points.
the patient had operation classified as either contaminated or dirty. or 5 1 point . 1 point .the duration of operation exceeds the 75th percentile .y 1 point . 4.the patient has an ASA preoperative assessment score of 3.
y standard T point (75% percentile) determined from NNIS database y the T point defined as length of time in hours that represents the 75th percentile of procedures .
but is not incapacitating . Physical Status Classification for Surgical Patients y Class I A patient in normal health y Class II A patient with mild systemic disease resulting in no functional limitations y Class III A patient with severe systemic disease that limits activity.y Table 1.
y Class IV A patient with severe systemic disease that is a constant threat to life y Class V A moribund patient not likely to survive 24 hours .
Operation T Point (hrs) s y y y y y y y y y y y y y y Operation T Point (hrs) Coronary artery bypass graft 5 Bile duct. or pancreatic surgery 4 Craniotomy 4 Head and neck surgery 4 Colonic surgery 3 Joint prosthesis surgery 3 Vascular surgery 3 Abdominal or vaginal hysterectomy 2 Ventricular shunt 2 Herniorrhaphy 2 Appendectomy 1 Limb amputation 1 Cesarean section 1 . liver.
allows recognition of SSI rates + classification of severity. deep incisional SSI. y Reporting of data stratified by risk and severity . and organ space SSI y This methodology.y newer definitions of superficial incisional SSI. + NNIS Risk Index.
and y At least 1 of the following: . y Involves only the skin or subcutaneous tissue.Superficial Incisional SSI y Occurs within 30 days after the operation.
erythema. local warmth of the wound) . Purulent drainage (culture documentation not required) Organisms isolated from fluid/tissue of superficial incision At least 1 sign of inflammation (eg. pain or tenderness. induration.
y Involves deep soft tissues (eg. fascia and/or muscle) of the incision.y Deep Incisional SSI y Occurs within 30 days of operation or within 1 year if an implant is present. and y At least 1 of the following: .
y Purulent drainage from deep incision minus organ/space involvement Fascial dehiscence or fascia separated by the surgeon Deep abscess identified by during reoperation. radiologically Surgeon declares deep incisional infection is present. histopathology. .
Wound is deliberately opened by the surgeon Surgeon or attending physician declares the wound infected. .
Organ/Space SSI y Organ/Space SSI y Occurs within 30 days of operation or within 1 year if an implant is present. y Involves structures not opened or manipulated operation y At least 1 of the following: .
y Purulent drainage from a drain placed by a stab wound y Organisms isolated from organ/space by aseptic culturing technique y Identification of abscess in the organ/space by direct examination. or by histopathologic or radiologic examination y Diagnosis of organ/space SSI by surgeon . during reoperation.
wound grading Southampton system 0 ± normal healing 1 ± normal healing with mild bruising/erythema 2 ± Erythema + other signs of inflammation 3.Clear or heamoserous discharge 4.Pus 5-Deep or severe wound infection with or without tissue breakdown .
ASEPSIS wound score y Additional treatment Antibiotic for wound infection 10 Drainage of pus under LA 5 Debridement of wound under GA 10 Serous discharge Daily 0-5 Erythema Daily 0-5 Purulent exudation Daily 0-10 Separation of deep tissues Daily 0-10 Isolation of bacteria 10 Stay greater than 14 days 5 .
Clinical features y Most have been mentioned along line y Local features which vary depending on stage. weight loss from increased catabolic loss . swelling. fever. discharge. type y Erythema . dehiscence y Systemic symtoms. gaping wound.
systemic signs Minor wound infections this may discharge pus or infected serous fluid but not excessive s .Major wound infection defined as a wound that either discharge significant quantity of pus spontaneously or secondary procedure to drain it +/.
Systemic manifestations y Sepsis is the systemic manifestation of a documented infection y SIRS is the body systemic response to an infected wound y MODS is the effect that the infection has on the whole body y MSOF is the end stage of uncontrolled MODS .
management y Detailed history y Thorough physical examination y Relevant investigations Gram stain Culture (both aerobic and anaerobic) Sensitivity testing Antigen and antibody testing Detecting of RNA and DNA sequencing PCR .
y Staining methods.Gram stain y Staining for fungal elements y Culture techniques y Fungal cultures can be requested .
radioimmunoassay . y Sensitivity testing then follows mainly for aerobic organisms.y Isolation of single colonies allows further growth and identification of the specific organism. y Newer techniques ELISA.
or Western blotting. U/E. respectively y Polymerase chain reaction (PCR) y FBC.y Detection of antibody in host sera y Detection of RNA or DNA sequences by Northern. Southern. FBS.SERUM PROTEINS .
y MRI.y Imaging Studies y Ultrasound can be applied to the infected wound area to assess whether any collection needs drainage. CT SCAN .
TREATMENT Local -Drainage -Debridement Systemic -resuscitation -appropriate antibiotics .
increase patient resistance General 1.Infrastructure theatre design 2 .Administrative policies antibiotic policies .block transfer 3 .prevention y Principles y Specific 1.removal of source of infection 2 .
Nicks and scrapes result in colonization Depilatory agents recommended occasionally result in a hypersensitivity .y patients to shower and scrub the surgical site with y y y y antiseptic soap dont shave or clipp evening before operation.
.y The presence of open skin wounds or infection of the hands or arms of the surgeon makes postponement of the operation desirable. y If the patient has any preexisting infection. SSI will be more likely.
y Isopropyl alcohol has excellent antiseptic qualities but is undesirable because of its flammability .y Prevention in the OR begins with the skin preparation y The site is cleansed with chlorhexidine or povidone iodine.
y Double gloving prevents blood "strike through" onto the surgeon's hands .y Povidone iodine should be allowed to dry before the incision y use of caps. and sterile surgical gloves. gowns. masks.
y Avoid blood ,fluid breakthrough especially on
surgeon's forearms y Avoid wet drapes y replace soaked gown &drapes. y Wide areas of skin prep around surgical site reduces risk of breakthrough
y Gas sterilization of instruments after thorough
cleansing of any particulate matter y Bowel prep y Achieving hemostasis at the surgical site is important
y process of controlling bleeding may itself increase
infection. y HB in soft tissues or wound space Is potent stimulus to microbial multiplication y exuberant use of electro cautery leaves necrotic tissue
y Prophylactic antibiotics Reduces incidence of post-op wound infections Directed against likely bacteria Given 30-60mins before operation Repeated if operation >4hours .
Incision should destroy as little tissue as possible(incision made through entire skin layer) .Tissue plane divided with few passes of the knife always beginning a new pass in the depths of the wound ± Ensure bleeding has stopped before closing wound ± .
Avoid wound edge desication Proper wound edge apposition Use of few sutures .
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