JINKA GENERAL HOSPITAL

SURGICAL SITE INFECTION PROTOCOL

BY QIU
NOVEMBER 2015/2022
JINKA SNNP ETHIOPIA
Table of contents

Contents Page
Table of contents..........................................................................................................................................1
Abbreviations...............................................................................................................................................2
Definition of Terms......................................................................................................................................3
Introduction..................................................................................................................................................4
Causes of Surgical Site Infections...............................................................................................................5
Signs and Symptoms of Surgical Site Infections.......................................................................................5
Types SSI, Time of Event, Extent of Tissue Involvement & Diagnostic Criteria of SSI.......................6
Risk factors for SSIs:...................................................................................................................................7
Investigations for SSI/Laboratory Studies................................................................................................7
Management/Treating Surgical Site Infections.........................................................................................7
Clinical Workflow to prevent SSI..............................................................................................................7
1 Follow Pre-Operative Measures..........................................................................................................7
2 Follow Intra-Operative Measures.......................................................................................................8
3 Follow Post-Operative Measures.........................................................................................................9
Education for Patients and Family Members...........................................................................................9
Barriers to SSI Prevention........................................................................................................................10
Complication of surgical site infection.....................................................................................................10
REFERENCES...........................................................................................................................................10

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Abbreviations
ABHR= Alcohol-Based Hand rub
AMR= Antimicrobial Resistance
CDC= Centers for Disease Control and Prevention
ECDC-= European Centre for Disease Prevention and Control
HAI= Health Care-Associated Infection
IDSA= Infectious Diseases Society of America
IPC= Infection Prevention and Control
MBP= Mechanical Bowel Preparation
MRSA =Methicillin-Resistant Staphylococcus Aurous
MSSA= Methicillin-Susceptible Staphylococcus Aurous
NHSN =National Healthcare Safety Network
NICE =National Institute for Health and Care Excellence
NNIS= National Nosocomial Infections Surveillance System
PVP-I= Povidone-Iodine
SAP= Surgical Antibiotic Prophylaxis
SSI= Surgical Site Infection
WHO =World Health Organization

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Definition of Terms
Health care-associated infection, also referred to as “nosocomial” or “hospital” infection, is an infection
occurring in a patient during the process of care in a hospital or other health care facility, which was not
present or incubating at the time of admission. Health care-associated infections can also appear after
discharge. They represent the most frequent adverse event during care.
Surgical Site Infection The CDC defines an SSI as an infection related to a surgical procedure that
occurs near the surgical site within 30 days following surgery (or up to 90 days following surgery where
an implant is involved)and it involves the skin and subcutaneous tissue of the incision (superficial
incisional) and/or the deep soft tissue (for example, fascia, muscle) of the incision (deep incisional) and/or
any part of the anatomy (for example, organs and spaces) other than the incision that was opened or
manipulated during an operation.
Transient flora refers to microorganisms that colonize the superficial layers of the skin and are more
amenable to removal by routine hand washing/hand rubbing.
Resident flora refers to microorganisms residing under the superficial cells of the stratum corneum and
found also on the surface of the skin.
Surgical procedure refers to an operation where at least one incision (including a laparoscopic approach)
is made through the skin or mucous membrane, or reoperation via an incision that was left open during a
prior operative procedure and takes place in an operating room.
Surgical antibiotic prophylaxis refers to the prevention of infectious complications by administering an
effective antimicrobial agent prior to exposure to contamination during surgery.
Surgical hand preparation refers to an antiseptic hand wash or antiseptic hand rub performed
preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora. Such
antiseptics often have persistent antimicrobial activity.
Alcohol-based hand rub refers to an alcohol based preparation designed for application to the hands to
inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one
or more types of alcohol, other active ingredients with excipients and humectants
Surgical skin preparation refers to the preoperative treatment of the intact skin of the patient within the
OR. Preparation includes not only the immediate site of the intended surgical incision, but also a broader
area of the patient’s skin. The aim of this procedure is to reduce the microbial load on the patient’s skin as
much as possible before incision of the skin barrier.
Mechanical bowel preparation refers to the preoperative administration of substances to induce voiding
of the intestinal and colonic contents.
Disinfection refers to either thermal or chemical destruction of pathogenic and other types of
microorganisms. Disinfection is less lethal than sterilization because it destroys most recognized
pathogenic microorganisms, but not necessarily all microbial forms (for example, bacterial spores). It
reduces the number of microorganisms to a level that is not harmful to health or safe to handle.
Sterilization refers to the complete destruction of all microorganisms including bacterial spores

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Introduction
Health care-associated infections (HAIs) are acquired by patients when receiving care and are the most
frequent adverse event affecting patient safety worldwide. Common HAIs include urine, chest, blood and
wound infections. HAIs are caused mainly by microorganisms resistant to commonly-used antimicrobials,
which can be multidrug-resistant. SSIs are potential complications associated with any type of surgical
procedure. Although SSIs are among the most preventable HAIs, they still represent a significant burden
in terms of patient morbidity and mortality and additional costs to health systems and service payers
worldwide.
According to a World Health Organization (WHO) report, the incidence of SSIs ranges from 1.2 to 23.6
per 100 surgical procedures. Worldwide, it has been reported that more than one-third of postoperative
deaths are related to SSIs. In addition, SSIs threaten the lives of millions of patients each year and
contribute to the spread of antibiotic resistance. Despite being a preventable complication of surgical
procedures, surgical site infections (SSIs) continue to threaten public health with significant impacts on
the patients and the health-care human and financial resources. According to recent evidence, the risk
factors for SSI are multifactorial and complex. For instance, pre-existing illness, wound contamination,
non-use of prophylactic antibiotics, presence of hypovolemic, longer duration of operation, longer
preoperative hospital stay, postoperative hospital stay ,advanced age, alcohol use , previous surgery, use
of drain , use of iodine alone in skin preparation, smoking, absence of wound care, and hair removal
inside operating room were factors associated with SSIs.
Though SSIs are among the most preventable healthcare-associated infections. However, according to the
available global evidence, SSIs impose significant burden to the patient and health care system in terms of
prolonged hospital stays, spend time in an intensive care unit, readmission to hospital, long-term
disability, contribute to spread of antibiotic resistance, increase treatment intensity, substantial financial
burden to health care systems, high costs for patients and families, deterioration in the quality of life, and
unnecessary deaths. Effectively controlling SSIs can reduce some of these negative effects, as up to one-
half of SSIs can generally be prevented through an improved adherence to established basic principles,
such as surgical hand preparation, skin antisepsis, adequate antibiotic prophylaxis, less traumatic, less
invasive and shorter surgery duration, improved hemostasis and avoidance of hypothermia.
The prevalence of SSI among postoperative patients in Ethiopia remains high with a pooled prevalence of
12.3% in 24 extracted studies. Therefore, situation based interventions and region context-specific
preventive strategies should be developed to reduce the prevalence of SSI among postoperative patients.

Our skin is a natural barrier against infection. Even with many precautions and protocols to prevent
infection in place, any surgery that causes a break in the skin can lead to an infection. Doctors call these
infections surgical site infections (SSIs) because they occur on the part of the body where the surgery
took place. If you have surgery, the chances of developing an SSI are about 1% to 3%.

Surgical site infections are a leading cause of in hospital morbidity, rates dependent on the type of surgery
performed. Primary prevention is the optimal way in reducing surgical site infections, with several
evidence-based interventions possible. Therefore, the prevention of these infections is complex and
requires the integration of a range of preventive measures before, during and after surgery.

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Causes of Surgical Site Infections
Infections after surgery are caused by germs. The most common of these include the bacteria
Staphylococcus, Streptococcus, and Pseudomonas. Germs can infect a surgical wound through various
forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through
germs in the air, or through germs that are already on or in your body and then spread into the wound.
SSIs can be caused by:
 Endogenous factors, such as from the patient’s flora or seeding from a distant site of infection.
 Exogenous factors, such as from surgical staff, physical environment and ventilation, tools,
equipment, and materials in the operating room.
The degree of risk for an SSI is linked to the type of surgical wound.
1) Clean wound: - refers to an uninfected operative wound in which no inflammation is
encountered and the respiratory, alimentary, genital or uninfected urinary tracts are not entered. In
addition, clean wounds are primarily closed and, if necessary, drained with closed drainage.
Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in this
category if they meet the criteria.
2) Clean-contaminated: - refers to operative wounds in which the respiratory, alimentary, genital
or urinary tracts are entered under controlled conditions and without unusual contamination.
Specifically, operations involving the biliary tract, appendix, vagina and oropharynx are included
in this category, provided no evidence of infection or major break in technique is encountered.
3) Contaminated wound: - refers to open, fresh, accidental wounds. In addition, operations with
major breaks in sterile technique (for example, open cardiac massage) or gross spillage from the
gastrointestinal tract, and incisions in which acute, non-purulent inflammation is
encountered ,including necrotic tissue without evidence of purulent drainage (for example, dry
gangrene), are included in this category.
4) Dirty or infected wound: - includes old traumatic wounds with retained devitalized tissue 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

Signs and Symptoms of Surgical Site Infections

Often appearing 5-7 days post-operatively, the common clinical features of surgical site infections
include:
 Spreading erythema
 Localized pain
 Pus or discharge from the wound
 Persistent pyrexia
Any SSI may cause redness, delayed healing, fever, pain, tenderness, warmth, or swelling. These are the
other signs and symptoms for specific types of SSI.

Types SSI, Time of Event, Extent of Tissue Involvement & Diagnostic Criteria of SSI

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Types Time to Extent of Clinical features Criteria for diagnosis
event* tissue
involvement
Superf Within 30 Skin and Peri-incisional pain or At least one clinical feature AND at least one of the
icial days of subcutaneous tenderness following:
incisio NHSN tissue
nal SSI procedure Localized peri-incisional  Purulent drainage from the superficial
swelling incision
Peri-incisional erythema or  Organisms are identified by culture (or
heat non-culture-based microbiologic testing
method) performed for clinical diagnosis or
treatment (eg, not surveillance)
 Incision opened by the surgeon (or other
designated clinician) because of concern
for superficial SSI◊
Deep Within 30 or Deep soft Fever (>38°C)  Purulent drainage from the deep incision
incisio 90 days of tissues of the
nal SSI NHSN incision such Localized pain or  Deep incision that spontaneously dehisces
procedure as the fascia tenderness or is opened by the surgeon (or other
and muscle designated clinician) because of concern
layers. for deep SSI AND organisms are identified
by culture (or non-culture-based
microbiologic testing method) performed
for clinical diagnosis or treatment (eg, not
surveillance). Presence of at least one
clinical feature, in absence of microbiologic
testing
Organ/ Within 30 or Any part of Clinical features for Appropriate clinical features specific to the
space 90 days of the body specific organ/space can organ/space AND at least one of the following:
SSI NHSN deeper than be found at the CDC
procedure the website§  Purulent drainage from a drain placed into
fascia/muscle the organ/space¥
layers that was As an example, for intra-
abdominal infection, at  Organisms identified from culture of fluid
opened or or tissue obtained from a superficial
manipulated least two of the following:
incision‡
during the Fever
procedure or (>38°C),Hypotension  Abscess or other evidence of infection
within an involving the organ/space detected on gross
abdominal or Nausea, vomiting, anatomical examination or histopathologic
joint cavity Abdominal pain or examination
tenderness, Elevated
transaminases ,Jaundice  Radiographic imaging findings suggestive
of infection

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Risk factors for SSIs:
 Having surgery that lasts more than 2 hours
 Having other medical problems or diseases
 Being an elderly adult/ Old age
 Trauma
 Being overweight
 Smoking
 Having cancer, Ischemia
 Having a weak immune system
 Low serum albumin concentration
 Having diabetes
 Having emergency surgery
 Having abdominal surgery etc.

Investigations for SSI/Laboratory Studies

The simplest, and usually the quickest, staining method involves:-
 Obtaining a Gram stain for infective organisms. Staining for fungal elements can be obtained at
the same time.
Other techniques include the following:
 Tests for antigens from the organism through enzyme-linked immunoassay (ELISA) or
radioimmunoassay
 Blood tests for infection markers (FBC, CRP) should be taken, alongside blood cultures if any
evidence of systemic involvement or sepsis.
 Detection of antibody response to the organism in the host sera
 Detection of RNA or DNA sequences or protein from the infective organism by Northern,
Southern, or Western blotting, respectively
 Polymerase chain reaction (PCR) to detect small amounts of microbial DNA
 Ultrasonography US) can be applied to the infected wound area to assess whether there is a
collection for which drainage is required

Management/Treating Surgical Site Infections

Most SSIs can be treated with antibiotics. Sometimes additional surgery or procedures may be required to
treat the SSI. During recovery, make sure that friends and family members wash their hands before and
after they enter your room. Make sure doctors, nurses, and other caregivers wash their hands, too.
Any sutures or clips present should be removed, allowing for the drainage of any pus and the opportunity
for wound packing if required.
Empirical antibiotic should be started; different wounds are often caused by different organisms (e.g. a
laparotomy wound infection is more likely to be caused by a coliform), therefore best practice is to follow
local empirical antibiotic guidelines. Antibiotic therapy can then be tailored following culture results.

Clinical Workflow to prevent SSI

1 Follow Pre-Operative Measures
 Consider all minimally invasive measures & Conduct MRSA screening.
 Assess the patient for any allergies
 Provide clear and understandable instructions of the procedure to the patient and their family
 Remove patient jewelry or any clothing that may be an obstruction during the surgery.

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  Administer antibiotics within one hour prior to any surgical incisions and re-dose as needed
 Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap,
either the day before, or on the day of, surgery.
 Do not use hair removal routinely to reduce the risk of surgical site
 If hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not
use razors for hair removal, because they increase the risk of surgical site infection.
 Give patients specific theatre wear that is appropriate for the procedure and clinical setting
 All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken.
 Staff wearing non-sterile theatre wear should keep their movements in and out of the operating area
to a minimum.
 Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection.
 The operating team should remove hand jewelry, artificial nails and nail polish before operations.
 Give antibiotic prophylaxis to patients before:
 Clean surgery involving the placement of a prosthesis or implant
 Clean-contaminated surgery
 Contaminated surgery.
 Do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery.
 Before giving antibiotic prophylaxis, take into account the timing and pharmacokinetics (for
example, the serum half-life) and necessary infusion time of the antibiotic. Give a repeat dose of
antibiotic prophylaxis when the operation is longer than the half-life of the antibiotic given.
 Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected
wound.
 Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and
afterwards if they have been given antibiotics during their operation
2 Follow Intra-Operative Measures
 Closely monitor the patient’s vital signs during the procedure. Minimize blood loss.
 Minimize traffic inside the operating room and maintain room humidity of 20-60%.
 Adhere to sterile precautions by enforcing strict hand scrub compliance and maintaining
 PPE the entire procedure. Note the PPE is not to be taken or worn outside of the operating room.
 Maintain protection and cleanliness of the site during the entire operation and perform topical
irrigation of the incision site. Maintain tight glucose and temperature control.
 The operating team should wash their hands prior to the first operation on the list using an
aqueous antiseptic surgical solution, with a single use brush or pick for the nails, and ensure that
hands and nails are visibly clean.
 Before subsequent operations, hands should be washed using either an alcoholic hand rub or an
antiseptic surgical solution. If hands are soiled then they should be washed again with an
antiseptic surgical solution.
 The operating team should wear sterile gowns in the operating theatre during the operation.
 Consider wearing 2 pairs of sterile gloves when there is a high risk of glove perforation and the
consequences of contamination may be serious.
 Prepare the skin at the surgical site immediately before incision using an antiseptic preparation
according to national protocol.
 If diathermy is to be carried out:
 Use evaporation to dry antiseptic skin preparations
 Avoid pooling of alcohol-based preparations.
 Do not use diathermy for surgical incision to reduce the risk of surgical site infection.
 Maintain optimal oxygenation & adequate perfusion during surgery.
 Do not use wound irrigation& intra cavity lavage to reduce the risk of surgical site infection.

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  Only apply an antiseptic or antibiotic to the wound before closure as part of a clinical research
trial. Consider using gentamicin-collagen implants in cardiac surgery.
 Cover surgical incisions with an appropriate interactive dressing at the end of the operation.
3 Follow Post-Operative Measures
 Ensure that all sponges, instruments, and needles used during the procedure are counted. Check
blood glucose levels, and vital signs.
 Practice proper disinfection process for all used equipment’s.
 Document wound care and maintain infection vigilance during the entire stay of the patient at the
hospital.
 Communicate key concerns for patient recovery with the full care team, including the patient and
family.
 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.
 Use tap water for wound cleansing after 48 hours if the surgical wound has separated or has been
surgically opened to drain pus.
 Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention
to reduce the risk of surgical site infection.
 Do not use Eusol and gauze, or moist cotton gauze or mercuric antiseptic solutions to manage
surgical wounds that are healing by secondary intention.
 Use an appropriate interactive dressing to manage surgical wounds that are healing by secondary
intention.
 Use a structured approach to care to improve overall management of surgical wounds. Enhanced
education of healthcare workers, patients and care givers, and sharing of clinical expertise is
needed to support.

Education for Patients and Family Members

Educate patients and family member clear, consistent information and advice throughout all stages of
their care. Patients and family members should understand
The definition of a surgical site infection
Their specific risk factors for a surgical site infection
Things the organization is doing to prevent a surgical site infection
Things they can be doing to prevent a surgical site infection, such as
 Obtain History about previous medical problems or previous SSIs
 Tell about health problems that could impact treatment (e.g. Allergies, etc.)
 Advice to stop/Quitting smoking if smoker
 Not applying powders, makeup, or lotions before the procedure
 Avoiding shaving where they will have surgery
 Showering just before the procedure
 Ensuring all providers practice hand hygiene
 Offer patients and care givers information and advice about how to recognize a surgical site
infection and who to contact if they are concerned.
 Offer patients and care givers advice on how to care for their wound after discharge
 Making sure all instructions for wound care and follow up are understood before discharge

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Barriers to SSI Prevention
Some common organizational barriers to safe surgery and SSI prevention include:
 Awareness: Current research suggests that up to 50% of nurses and healthcare staff are unaware
of the evidence-based recommendations to prevent SSIs (Lin et al., 2019).
 Attitudes: It has been suggested that clinicians may not agree on the standardized protocols or
may not feel confident in their abilities to execute these standards effectively. Providers may not
agree that the presented evidence is applicable to their patient’s situation. Hospital leaders should
evaluate the number of steps in SSI prevention standards to better understand the operational
barriers that even the well-intended clinicians may face (AHRQ, 2017).
 Detection: Detecting SSIs is becoming increasingly challenging due to the lack of standardized
methods for post- discharge and outpatient surveillance. This is in part due to an increased
number of outpatient surgeries and shorter post-operative inpatient stays.

Complication of surgical site infection

Surgical wound infection complications can be categorized into local and systemic ones.
Local complications include delayed and non-healing of the wound, cellulitis, abscess formation,
osteomyelitis as well as further wound breakdown.
Systemic complications include bacteremia with the possibility of distant hematogenous spread and
sepsis.

REFERENCES
1. Patient Safety Movement Foundation. (2022). Surgical Site Infections (SSI) Actionable Patient
Safety Solutions. Retrieved from https://patientsafetymovement.org/community/apss/
2. Surgical site infection and its associated factors in Ethiopia: a systematic review and meta-analysis
BMC Surgery volume 20, Article number: 107 (2020)
3. Smith MA, Dahlen NR, Bruemmer A, Davis S, Heishman C. Clinical practice guideline surgical site
infection prevention. Orthop Nurs. 2013; 32(5):242–8
4. GLOBAL GUIDELINES FOR THE PREVENTION OF SURGICAL SITE INFECTION WHO 2018
PDF
5. Overview of the evaluation and management of surgical site infection www.uptodate.com © 2022

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