Surgical Site

Infection
Anak Agung Istri Intan Yuniari
Surgical Site Infection (SSI)

Infections occurring up to 30-90

days after surgery and affecting
either the incision or deep tissue
at the operation site

SSI associated with substantial

mortality and morbidity

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
 Incidence varies widely between
procedures, hospital, surgeon and
patients

CDC: SSI is the third most frequently

reported nosocomial infection (38%
Epidemiolog among surgical patients)

y The incidence is lower in those

minimally invasive procedures due to

• Smaller incision
• Earlier mobilization
• Reduction in post operative pain
• Decreased use of central venous catheter

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
 Readmission to hospital or ICU treatment

Impact of Higher risk of death (relative risk is 2.2

compared with those without SSI)
SSI on
healthcare Higher healthcare cost

resources Deep infections are associated with longer

LoS (Length of Stay) or hospitalization

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
National Healthcare Safety Netwrok. Surgical Site Infection Event (SSI). Centers Dis Control Prev. 2021.
 Risk Factors

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
Microbiology of
SSI
Bacteria frequently associated with
SSIs include :
• Staphy­lococcus aureus
• Coagulase- negative
staphylococci
• Entero­coccus sp
• Escherichia coli

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
 Preparation of the patient

• Treat infection
• Do not remove hair, unless it will interfere the operation
• Adequately control blood glucose
Preoperative •
•
Do not withhold necessary blood product
Require patient to shower or bathe with antiseptic agent
• Use antiseptic for skin preparation

(Principles Hand/forearm antisepsis

Recommendation of • Keep nail shorts

• Perform preoperative surgical scrubs. Scrub hands and

CDC) forearm up to the elbow

Antimicrobial prophylaxis

• Antimicrobial prophylaxis only when indicated

• Administer initial dose IV
• Before elective colorectal operation, prepare the colon by
use of enemas

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention
of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
 Principles
Recommendation
of CDC

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the
Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
 Principles
Recommendation
of CDC

Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017;152(8):784–91.
Conclusion

• SSIs impose a substantial burden of mortality and morbidity

• It is important to recognize that much of this burden of morbidity
and mortality associated with SSIs is preventable
• CDC guidelines for prevention of SSI is divided into preoperative,
intraoperative and postoperative care
Kasus
Asnawi, 67 tahun, 455-12-10

KU:
Pasien dikonsulkan oleh TS Urologi dengan TCC buli cT2N0M0 Post TURBT, Riwayat UTUC kanan post RNU
kanan (Juli 2019), Riwayat TURBT tidak habis (Juli 2020), Riwayat sistoskopi + evakuasi clot + koagulasi + TURBT
(Oktober 2021), Anemia (7,7), hiponatremia (130), hipoalbuminemia (2,4) Pro tindakan radikal sistektomi + ileal
conduit

RPS:
Pasien datang dengan keluhan lemah badan dan BAK merah sejak 1 bulan SMRS. Pasien awalnya juga mengalami
keluhan yang sama pada Juli 2019. Saat itu, dilakukan CT-Scan di RS Polri, didapatkan tumor ginjal kanan dan
dilakukan RNU kanan + radiasi 28x di RS Dharmais. Juli 2020, keluhan hematuria muncul kembali, dilakukan
sistoskopi dan didapatkan tumor buli lalu dilakukan TURBT dan kemoterapi intravesika 8 siklus namun tidak
membaik, pasien dirujuk ke RSCM. Oktober 2021, pasien dilakukan TURBT dan sempat BAK jernuh. 1 bulan lalu,
pasien mengeluhkan BAK merah kembali diserai gumpalan. Pasien disarankan untuk radikal sistektomi dan ileal
conduit, namun saat sedang toleransi operasi, pasien lemas dan dibawa ke IGD. Keluhan demam, mual muntah saat
ini tidak ada.
• O/
• Compos mentis,
• TD 119/71 mmHg
• HR 76x/menit
• RR 18x/menit
• T:36.5
• SpO2 97% room air

• Mata : konjungtiva anemis, sklera tidak ikterik

• Jantung: S1-S2 Reguler, murmur ataupun gallop tidak ada
• Paru: Vesikuler bilateral, rhonki ataupun wheezing tidak ada
• Abdomen :
• Inspeksi: datar
• Auskultasi: bising usus positif
• Perkusi: Timpani
• Palpasi: supel, nyeri tekan tidak ada
• Ekstremitas : akral hangat, CRT<2
• A/
-Post TURBT a.i. gross hematuria ec TCC buli cT2N0M0
-Riwayat UTUC kanan post RNU kanan (Juli 2019)
-Riwayat TURBT tidak habis (Juli 2020)
-Riwayat sistoskopi + evakuasi clot + koagulasi + TURBT (Oktober 2021)
-Anemia (7,7)
-Hiponatremia (130)
-Hipoalbuminemia (2,4)

• P/
Pro Radikal sistektomi + ileal conduit
- persiapan ERAS dari Urologi
- persiapan Colon dari bedah
 S/ pasien dikeluhkan sesak dan tampak lemas

O/ Tampak sakit berat

TD 125/67 mmHg

Follow up
HR 96x/menit
S 36,9

22/2/2022
RR 24x/menit, SpO2: 98% (O2 15 liter/menit via trachvent)

(Lab 21/2/22)
DPL 10.6/31.2/25.740/424.000
(sebelumnya tanggal 18/02/22: DPL 10.5/30.4/10.500/435.000)
PT/aPTT 1,15x/1,60x
Na: 133/ K: 6,3/ Cl: 107,2 (sebelumnya 16/02/22: Na: 134/ K: 5,1/ Cl: 105,7)
Laktat: 3,6
• Kultur swab dasar luka 22/1/22
• SPECIMEN SITE : luka operasi
• ISOLATE 1 : Klebsiella pneumoniae
• 
• Susceptibility Isolate 1
• -------------- ---------
• Gentamicin......................... R
• Cefotaxime......................... R
• Ceftriaxone........................ R
• Ceftazidime........................ R
• Piperacillin/Tazobactam............ R
• Doripenem.......................... R
• Tigecycline........................ R
A/
POD-43 radical cystectomy dan ileal conduit, POD-41 post-repair anastomosis ureteroileal
dan reseksi ileum non-vital, POD-28 trakeostomi, POD-14 organ debridement dan primary
suture a.i. IDO dan burst abdomen, POD-0 nefrostomi ren sinistra (Pukul 18.42, 21/2/2022)

P/
- Awasi produk stoma
- GV 2 kali sehari dengan kassa biasa, tutup dengan perekat transparan
- Terapi lain lanjut sesuai TS urologi
- Pro NPWT 
-D10 Polymixin B 2x750000 IV drip 3 jam
-D10 Imipenem Cilastatin 4x1 gram IV drip 3 jam
-Insulin 10 U dalam D40% 50 ml/6 jam
-Omeprazole 2x40 mg IV
-Paracetamol 3x1 gram IV
-Ibuprofen 3x400mg IV bila S>39 C
-Digoxin 1x0.25 mg IV
-VIP Albumin 3x2 sach PO
-Kalitake 3x5 gram PO
-Apialis 1x20 ml PO
-Zinc 1x20 mg PO
-Sucralfat 3x15 mL PO
-Fluimucyl 2x300 mg IV
-Loperamid 2x2 mg PO
Case
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