FACULTY OF MEDICINE, UM

Bacteriology of Wound
Infections
Department of Medical Microbiology
Faculty of Medicine
Universiti Malaya
  Accidental/intentional
 Clinical diagnosis
Wound

 Microbiology results
Types of Wounds

 Traumatic
 Surgical
 Burns
 Animal bites
SURGICAL SITE INFECTIONS (SSI)
 Very common and important HAI
 Next in frequency to nosocomial UTI
(24% of total HAI)
 Increase cost, morbidity and mortality
 posing significant challenges to those
required to prevent, diagnose and treat
 FINANCIAL BURDEN

In U.S., >40 million inpatient surgical

Impact of SSI

procedures each year; 2-5%

complicated by surgical site infection
Prolong hospital stay by 7.4 days
Cost $400-$2,600 per infection
(TOTAL: $130-$845 million/year)
CDC Definition of Surgical Site
Infections

SSI level classification

 Incisional SSI
- Superficial incisional = skin and subcutaneous
tissue
- Deep incisional = involving deeper soft tissue

 Organ/Space SSI
- Involve any part of the anatomy (organs and
spaces), other than the incision, opened or
manipulated during operations
SURGICAL SITE INFECTIONS

confined to incisional wounds

(60-80%)
may involved structures
adjacent to wounds (deep
infections)
Which of the following is a common clinical
presentation of SURGICAL SITE INFECTION?

1. Pain/tenderness
2. Swelling
3. Redness/erythema
4. Purulent drainage / discharge
5. All of the above
 At least one of the following is present:
SIGNS OF SSI

 Purulent discharge from the surgical site

 Purulent discharge from wound or drain placed in
wound
 Organisms isolated from aseptically obtained wound
culture
 Must be at least one of the signs and symptoms of
infection – pain or tenderness, localised swelling, or
redness/heat.
 Other signs of wound infection include:

 Delayed healing not previously anticipated.

SIGNS OF SSI

 Discolouration of tissues both within and at the wound margins.

 Abnormal smell coming from wound site.
 Friable, bleeding granulation tissue despite appropriate care and
management.
 Lymphangitis, a red line originating from the wound and leading
to swollen tender lymph glands draining the affected area
SOURCES OF PATHOGEN

ENDOGE ENVIRON
NOUS MENTAL

SEEDING CONTAMI
FROM NATED
DISTANT MATERIA
FOCUS L
Which of the following is the most common
causative agent of surgical site infection?

1. Enterobacter spp
2. Candida albicans
3. Pseudomonas aeruginosa
4. Staphylococcus aureus
5. Escherichia coli
 Microbiology of SSIs (CDC)
1986-1989
(N=16,727)

Pseudomonas Staphylococcus
aeruginosa aureus
8% 17% 1990-1996
(N=17,671)
Enterococcus
spp. Pseudomonas Staphylococcus
8% aeruginosa aureus
8% 20%

Enterococcus
Escherichia spp.
Coagulase neg. 12%
coli staphylococci
10% 12%

Escherichia Coagulase neg.

coli staphylococci
8% 14%
SURGICAL SITE INFECTIONS
> 60% of infections are caused by
 Coagulase –ve Staphylococci
 Enterococcus spp
 Pseudomonas aeruginosa
 Enterobacteriaceae
SURGICAL SITE INFECTIONS
Factors affecting change
 immunocompromised patients
use of prophylactic antibiotics
 increase use of foreign
materials
 prolong surgical procedures
 Economic Impact
Staphylococcus aureus & epidermidis

Cost of care
(separate by methicillin susceptibility)

Resistant Susceptible

$107,264 $68,053

Parvizi et al. J Arthroplasty 2010;25:103

Pathogenesis of SSI
Relationship equation

Dose of bacterial contamination x Virulence

---------------------------------------------------------------
Resistance of Host

SSI Risk
SSI Risk Factors
Age Hair removal/Shaving
Obesity Duration of surgery
Diabetes Surgical technique
Malnutrition Presence of drains
Prolonged preoperative Inappropriate use of
stay antimicrobial prophylaxis
Infection at remote site
Systemic steroid use
Nicotine use
CLASSIFICATION OF SURGICAL WOUNDS and RISK
OF SSI
According to the likelihood and degree of contamination

Clean wounds
 a non-traumatic wound
 no inflammation
 no break in technique
respiratory,alimentary,genitourinary tracts were not entered
Pathogens : exogenous
CLASSIFICATION OF SURGICAL WOUNDS
According to the likelihood and degree of contamination

Clean-contaminated wounds
 a non-traumatic wound
 a minor break in technique
 respiratory,alimentary,genito-urinary tracts were
entered with no significant spillage
Pathogen : endogenous
CLASSIFICATION OF SURGICAL WOUNDS
According to the likelihood and degree of contamination

Contaminated wounds
 a fresh traumatic wound
 gross contamination present at surgical site but in
absence of obvious infection
Pathogen : endogenous
CLASSIFICATION OF SURGICAL WOUNDS
According to the likelihood and degree of contamination

Dirty wounds
 Active infection is present
 gross spillage from GIT or entrance into GU or biliary
tract in the presence of infected urine or bile
 include dirty wounds with retained devitalised tissue or
pus from any source
Pathogen : that of active infection
 SURGICAL WOUNDS
Risk of infections

CLEAN
CLEAN CONTAMINATED
CONTAMINATED DIRTY

1-5%
3- 10- 30-100%
11% 20%
SURGICAL WOUNDS

Clean wound infection rates (for a given

operation)-useful measure for surveillance ,
research and QA
 compare surgeon’s infection rates
 compare operating techniques
 alert personnel to wounds at high risk of
infection
CLEAN WOUND INFECTION RATES

<1%
EXEMPLARY

1-
2%
ACCEPTABLE

>2
REQUIRE INVESTIGATIONS
 1. PRE-OP PREPARATION OF PATIENT
RECOMMENDATIONS

 TREAT INFECTIONS , UNDERLYING

CONDITION
 SHORT PRE-OP STAY (1.1%, 2%-2wks stay, 3.4%>
2wks)
 BATHING WITH ANTISEPTICS (No bath-2.3%,Bath
soap-2.1%, antiseptics-1.3%)No evidence of benefit to reduce
SSI, reduce skin microbial colony counts
 HAIR CLIPPING/ DEPILATORY (sharp razor>electric
razor>depilatory)(shaving >24hrs preop-SSI risk 20% vs 7%
just before)
Pre-operative Antiseptic
Showers/Baths
Most studies examine effects on skin colony counts
antiseptic showering decreases colony counts

Few studies examine effect on SSI rates

Shower No Shower
Cruse, 1973 2.3% 1.3%

Ayliffe, 1983 4.9% 5.4%

Rooter, 1988 2.4% 2.6%

Pre-operative Shaving/Hair Removal
Seropian, 1971
Method of hair removal
Razor = 5.6% SSI rates
Depilatory = 0.6% SSI rates
No hair removal = 0.6% SSI rates

Timing of hair removal

Shaving immediately before= 3.1% SSI rates
Shaving  24 hours before = 7.1% SSI rates
Shaving >24 hours before = 20% SSI rates
Pre-operative Shaving/Hair Removal

Multiple studies show

- Clipping immediately before

operation is associated with lower
SSI risk than shaving or clipping
the night before operation
2. SURGICAL TEAM
■ DRESS CODE
■ SHOE COVERS?
■ SCRUB
■ STERILE GOWN / GLOVES
■ LINEN DRAPES
3. OPERATION TECHNIQUE
 EFFICIENT
 GENTLE TISSUE
HANDLING
 REDUCE BLEEDING
 DRAINAGE - CLOSE
4. OT ENVIRONMENT
 VENTILATION 20 AIR
CHANGES / HR
 OR DOORS
 CLEANSE BETWEEN OPS
 STERILE SURGICAL
INSTRUMENTS
 5. WOUND CARE

UMMC  GLOVES

SAYS: WHEN
TOUCHING
WOUNDS
WASH  CHANGE

YOUR DRESSING IF
WET S/S OF
INFECTIONS
HANDS
 6. PROPHYLACTIC ANTIMICROBIALS

 PARENTERAL FOR HIGH RISK

 SAFE AND EFFECTIVE
Role of Antimicrobial Prophylaxis (AP)
in Preventing SSI
Refers to very brief course of an antimicrobial
agent initiated just before the operation begins
Should be viewed as an adjunctive preventive
measure
Appropriately administered AP associated
with a 5-fold decrease in SSI rates
Importance of Timing of Surgical Antimicrobial
Prophylaxis (AP)
 Prospective study of 2,847 elective clean and clean-
contaminated procedures
EARLY AP
2-24 HRS
BEFORE •3.8%
INCISION
POST-OP AP
3-24 HRS
AFTER •3.3%
INCISION
PERI-OP AP
<3 HRS AFTER
INCISION
•1.4%
PRE-OP AP
<2 HRS
BEFORE • 0.6%
INCISION

Classen, 1992 (NEJM 326:281-286)

Impact of Prolonged Surgical
Prophylaxis
DESIGN: Prospective
POPULATION: CABG patients (N=2641)
Group 1: pts who received < 48 hours of
AP
Group 2: pts who received > 48 hrs of AP
Impact of Prolonged Surgical AP

OUTCOME
• Incidence of SSI
RESULTS: 43% of patients received AP > 48
hr
SSI Incidence
• <48 hrs group: 8.7% (131/1502) vs
• >48 hrs group: 8.8% (100/1139), p=1.0

Harbath S : Circulation 2000; 101: 2916-2921

 Impact of Prolonged Surgical
Prophylaxis

Conclusion
ABP for CABG :
 prolonged prophylaxis does not reduce the rate of
SSI
 is associated with an increased risk of acquired
antibiotic resistance
7. PROTECT PATIENTS FROM OTHERS
INFECTED

 ISOLATION
 INFECTED STAFF
 NO ROUTINE CULTURING
 WARD CLOSURE
8. SURVEILLANCE
 ICN – MONITOR SITUATION,
COMPUTE DATA, DISSEM. INFO
 DATA MADE AVAILABLE TO –
ICC, SURGICAL DEPTS. AND
SURGEONS
 HIGH CLEAN WOUND
INFECTION RATES: EPID.
STUDY
 F/U OF DISCH. PTS. – 30 DAYS
POST-OP
 PARTING WORDS ON SSI

From an academic standpoint, we still lack a complete

understanding of exactly when the surgical site starts to
develop infection, what the premises that drive microbial
colonization to infection are and why some patients get
infected and others do not. There is certainly enough
room to improve work up of the pathogenesis, search for
hidden risk factors lurking inside large databases and to
implement well-conducted randomized studies.

Preventing Surgical Site Infections

Ilker Uçkay; Stephan Harbarth; Robin Peter; Daniel Lew; Pierre
Hoffmeyer; Didier Pittet
Authors and Disclosures
Posted: 07/21/2010; Expert Rev Anti Infect Ther. 2010;8(6):657-
670. © 2010 Expert Reviews Ltd.
 BURN WOUNDS

About 500,000 persons are treated for burn injuries

IN USA

-40,000 are hospitalised

-About 10% dies ( majority due to residential fires)
-75% die at the scene
-Of those that reach the hospital- morbidity and
mortality are due to infections
various types of burn wound infections
wound colonization,
wound infection,
invasive infection,
cellulitis, and
necrotizing infection/fasciitis
BURN WOUND INFECTION
 DIFFICULT TO ASCERTAIN
 COMMON WITH SIGNIFICANT
MORTALITY
 DESTRUCTION OF MECH. BARRIER
 COAGULATION OF PROTEINS
 DISORDER OF NEUTROPHIL FUNCTION
IMPAIR HUMORAL AND CELLULAR
IMMUNITY
three categories-1st,2nd,3rd

First Degree
damage to the topmost
layer of the skin, the
epidermis

Second degree
Damage to the epidermis
as well as dermis

Third Degree
damage or destruction of the entire depth of the
skin as well as tissues that lie beneath it.
 BURN WOUND INFECTION
Types of burns and risk of infection
First degree : low risk
second : if infected, may convert
to full skin
third : high risk

RISK IS DIRECTLY RELATED TO INJURY

 Risk factors
Extremes of age

Comorbidities such as obesity and diabetes

Immunosuppression (eg, due to AIDS)

Invasive devices (eg, catheters)

Full-thickness burns
The pathogens

GRAM POSITIVE
COCCI – + MRSA
GRAM NEGATIVES
BACILLI-
PSEUDOMONAS
AERUGINOSA
ACINETOBACTER SPP
KLEBSIELLA SPP
OTHERS
FUNGAL PATHOGEN
CANDIDA
 SUPPURATIVE
SEPARATION OF
ESCHAR

SIGNS OF Wound infection GRAFT REJECTION

+ AND CHANGING OF
CELLULITIS COLOUR

GREENISH
DISCOLOURATION OF
SUBCUTANEOUS FAT
 Pseudomonas aeruginosa in burn
wounds

 Plants
 Water
condensation in
Source:
instruments
 Dilute
disinfectants
 Carriage
 Hospital
environment
Pseudomonas aeruginosa burn wound

Control
Readily killed by phenolics and drying
High conc. of sulphonamide compounds

Treatment
Invasion of blood stream/ deeper tissues
i/v aminoglycosides/ amikacin, imipenem
 Strept. pyogenes burn wound

 Potentially serious
 Delay healing
 Graft failure
 Rapidly fatal – septiceamia
 If isolated – indication of therapy
 FUNGAL BURN WOUND
 BLACKENED DISCOLOURATION
 HISTOLOGICAL CONFIRMATION
 PHYCOMYCETES
 CANDIDA
 ASPERGILLUS
 DIAGNOSIS OF BURN WOUND INFECTION
 Surface culture
Limited value, evaluate potential pathogen, actual
wound status not indicated
 Wound biopsy with quantitative culture
Accurate indication, histologic evidence of invasion
of viable tissues, 105/> bacteria/gm tissue
 BURN WOUND INFECTION

Bacterial Invasion :
 Haemorrhage
 Rapid eschar separation
 Greenish discolouration
 Topical antimicrobials
( reduce incidence of conversion from partial to
full thickness)

1. Silver nitrate in a 0.5% solution

effective before colonization, continous
occlusive dressing, limit evaluation and range
of movement
 Topical antimicrobials
( reduce incidence of conversion from partial to
full thickness)

2. Mefenemide acetate (sulfamylon)

broad spectrum, penetrate burn eschars, easy
wound evaluation, transient burning
sensation, post-injury hyperventilation
 Topical antimicrobials
( reduce incidence of conversion from partial to full
thickness)

3. Silver sulphadiazine (SSD)

Good activity, best used as prophylaxis,
soothing, resistant reported
THANK YOU