1. Mangram, A. J., Horan, T.C., Pearson, M.L, Silver, L.C., & Jarvis, W. R. (1999).

Guideline for
Prevention of Surgical Site Infection, 1999. Hospital Infection Practices Advisory Committee.
Infection Control Hospital Epidemiology, pgs. 250-278.

Surgical Site Infection (SSI) refers to an infection that occurs after an operation within 30 days if no
implant or within one year if with implant. (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). SSIs are
divided into three types, depending on the depth of the infection penetrating into the surgical wound:
Superficial incisional infection, Deep incicion infection, and Organ/Space Infection.

According to National Nosocomial Infection Surveillance (NNIS) System and the Centers for Disease and
Control and Preventon (CDC), SSI accounted for 14% to 16% of all nosocomial infections and was the
most common health-care associated infections among surgical patients in the United States (USA)
(Mangram et al.).

For prevention of SSI, nurses should have proper knowledge and they should have skills on this matter
during pre-operative, intra-operative, and post-operative period. Pre-operatively, nurses need to have
knowledge and they should provide care in the following scopes: Hygiene and skin preparation,
controlling underlying medical conditions, maintaining nutritional status, and antibiotic prophylaxis. Post
operatively, nurses also need to have knowledge and maintain good practice in the following scopes:
Surgical wound care with aseptic precaution, wound assessment and monitoring of SSI, and nutritional
support.

SSI is one of the most common nosocomial infections among surgical patients. In United State of
America, Surgical site infection account for 14%-16% of all health care associated infections (Mangram
et al, 1999).

2. SSI is one type of nosocomial infection in which a surgical infection occurs after invasive
procedures (Luksamijarulkul, Parikumsil, Varaporn, & Konkeaw, 2006).

Surgical Site Infection (SSI) refers to an infection that occurs after an operation within 30 days if no
implant or within one year if with implant (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). SSI is one
type of nosocomial infection in which a surgical infection occurs after invasive procedures
(Luksamijarulkul, Parikumsil, Varaporn, & Konkeaw, 2006). According to National Nosocomial Infection
Surveillance (NNIS) System and the Centers for Disease and Control and Preventon (CDC), SSI accounted
for 14% to 16% of all nosocomial infections and was the most common health-care associated infections
among surgical patients in the United States (USA) (Mangram et al.).
Incidence of SSIs may vary in different countries. Developed countries, such as USA, United Kingdom
(UK), and Sweden have lower incidence of SSIs ranging from 2% to 6.4% (Anderson, Kaye, Classen, Arias,
& Podgomy, 2008; Gunningberg, Persson, Akerfeldt, Strdsberg, & Swenne, 2008; Taylor et al., 2004). In
developing countries, such as India, Pakistan, Nepal, Turkey, and Iran, the incidence of SSIs is higher
ranging from 5.5% to 25% (Desa, Sathe, & Bapat, 2008; Giri, Pant, Shankar, Sreeramareddy, & Sen, 2008;
Lohsiriwat, 2009Mustafa, Buhkari, Kakru, Tabish & Qadri, 2004: RAzavic, Ibrahimpoor, KAshani, &
Jafarian, 2005).

This chapter provides a review of existing relevant literature on operating room nurses knowledge,
attitude and practice of sterile techniques as an important means to prevent surgical site infections in
healthcare settings. Resources and data sources that provide adequate information were accessed.
Some of these include; databases of electronic journal articles and search engines such as Cinalhl,
Medline, Pub Med, Science direct and other websites of Health systems, World Health Organization.
Moreover, books, journals and past dissertations related to the topic were also consulted.
Williams et al (2007) have explained the operating room as a dynamic, high-pressure and high risk
setting which is susceptible to numerous errors. The modern surgery obliges a set of trained people to
work mutually in a team. The operating room staffs should be able to deal with the demands of their
complex work environments and effectively deliver safe surgical patient care (Mitchell & Flin, 2008).

Surgical site infections (SSI) previously referred to as wound infection is one of the most common causes
of health care associated infection. It is also one of the most important complications of a surgical
intervention. Its occurrence significantly prolongs duration of patients' hospital stay, and increases the
risk of morbidity and mortality. Certain factors, intrinsic and extrinsic, are known to be responsible for
surgical site infections. Intrinsic factors include advanced age, malnutrition, metabolic diseases,
smoking, obesity, hypoxia, immune-suppression, and length of preoperative stay. Extrinsic factors
consist of application of skin antiseptics, pre-operative shaving, antibiotic prophylaxis, and pre-operative
skin preparation, inadequate sterilization of instruments, surgical drains, surgical hand’s scrubs, and
dressing techniques.

The incidence of surgical site infection in Bangladesh range from 11% - 30% (Parvin et al, 2001).
However, there is a paucity of information about surgical site infection in Nigeria. In fact, it has been
suggested that the incidence of surgical site infections may be higher due to poor state of health
facilities.

Surgical site infection is an infection that occurs after an operation within 30 days if no implant or within
one year if an implant is administered in the organ (Mangram et al., 1999). The cardinal signs of wound
infection are pain, tenderness, localized swelling, redness or heat.

Post operative wound infection is a major source of illness and a less frequent cause of death among
surgical patients (Nichols, 2004). Post operative infection is the most common nosocomial infection and
according to the Centre for Disease Control (2008), 67% of these infections occur within the incision and
33% occur in an organ or space around the surgical site. Surgical wound infection is mostly caused by
extrinsic contamination of an intravenous agent (such as propofol) by the anaesthetic personnel who
harbored pathogens in lesions on their hands, scalp and in their nares. Lapses in aseptic techniques and
reuse of single use vials for several patients are contributory factors in the occurrence of surgical wound
infections.
Surgical wound infections prolong patients’ hospital stay, and increase cost of care. It places a greater
economic burden on the patient and family. Efforts to reduce the frequency and severity of surgical
wound infection continue to focus on peri-operative issues, infection control practices in the operating
room, preparation of a surgical site, timing and choice of antibiotics, and physiologic support of a patient
during and immediately following a procedure. The peri-operative nurse is an important infection
control agent. It is important for the surgical nurses to understand the basic pathophysiology of post-
operative wound infection and the evidence for preventive strategies.

The implementation of quality measures including antibiotic prophylaxis, hair removal using a clipper,
tight control of pre- and post-operative glucose levels and avoiding hypothermia are all recognized key
quality measures in reducing infection (Wick et al., 2008). The timing of surgical prophylaxis and the
appropriate use of antimicrobial prophylaxis is an agreed quality indicator and represents a significant
intervention in preventing SSIs (McKibben et al., 2005; Humphreys and Cunney, 2008). There is need for
nurses to have adequate knowledge about the preventive measures to ensure quality care for the post
operative patients. The objectives of this study were to assess nurses’ level of knowledge of post
operative wound infection and evaluate their practice regarding postoperative wound infection
prevention.

Surgical site infections (SSI) are still one of the most frequent causes of morbidity and mortality
following any surgical procedure. In 2010, an estimated 16 million operative procedures were
performed in acute care hospitals in the United States (1). A recent prevalence study found that SSIs
were the most common healthcare-associated infection, accounting for 31% of all nosocomial infections
(2). The Center for Disease Control healthcare-association infection (HAI) prevalence survey estimated
that 157,500 cases of SSI are associated with in-patient surgeries in 2011 (3)

Surgical-site infections tripled the odds of dying during or soon after an operation, the study found. Altogether,
five percent of the operations reviewed for the study resulted in death.

“The cost of a surgical site infection — in terms of mortality, morbidity, health-care costs, and loss of
productivity — is enormous,” Robert Sawyer, a researcher at Western Michigan University’s Homer Stryker
M.D. School of Medicine, said in a comment.

More than 12 percent of people who have gastrointestinal surgery become infected within 30 days of going
under the knife, researchers said Wednesday in a study covering 66 countries.

For low-income nations, the incidence of so-called surgical site infection was double the global average,
according to thresults, based on data compiled by a consortium of 2,500 doctors and researchers.In wealthy
countries, the rate of post-op infection was nine percent, and for middle-income nations it was 14 percent.