Prevention of Surgical Site Infections (SSI)

Learning objectives

1. Explain the relevance and impact of SSI.

2. Identify the risk factors associated with SSI.

3. Describe the main recommendations to prevent SSI.

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Time involved

• 35-40 minutes

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Background - 1

• One of the most important healthcare associated infections

• 25% of all HAIs• 40% to 60% preventable

• High cost • prolong hospital stay • increase antimicrobial and laboratory costs• require added health care interventions

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Background - 2• Sterilisation, aseptic technique, clean air,

and prophylaxis have reduced SSI • The numbers are still high

• Important cause of morbidity and mortality• Multi-factorial

• Difficult to determine the exact cause

• Higher in developing nations

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Factors that influence transmission of infection• Patient risk factors• Types of surgical procedures• Operating room environment

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Patient risk factors

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Proven ControversialUncontrolled Diabetes Nutrition status

Obesity especially in orthopaedic and cardiac

Coexisting remote infection

Smoking

Colonisation with microorganisms

Perioperative transfusion

Length of preoperative stay

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Operative Risk Factors - 1

• Colonisation of the operative site • Antiseptic bath• Skin antisepsis (consider clorhexidine)

• Colonisation of the surgical team • Surgical scrub with antiseptic• No artificial nails

• Preoperative shaving• Infected or colonised surgical personnel

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Operative risk factors - 2

• Duration of operation• Contamination of the operative site• Antimicrobial prophylaxis• Foreign material in the surgical site

• sutures and drains

• Hypothermia• Surgical technique

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Environmental risk factors

• Operating room ventilation• Number of people in OR• Inanimate surfaces• Inadequate sterilisation• Surgical clothes, gloves and masks

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Ventilation system

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Surveillance• Shown to reduce SSI risk• Post-discharge surveillance essential • Should include

• Standard definitions• Risk stratification

• Typical definition• Purulent drainage from the incision site or from the

site of a drain with either a positive or negative culture

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Risk stratification• Based on a specific surgery

• Cholecystectomy, hernia repair, Caesarean section, hip replacement

• Specific risk of patients • Type of surgery

• Clean, clean-contaminated, contaminated, or dirty

• Compare the clean wound SSI rates among different surgeons

• Patient index• Standardised infection ratios

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Basic Recommendations for Prevention – Preoperative - 1• Identify and treat all infections • Good control of diabetes• Minimum hospital stay • Do not remove hair preoperatively

• If essential, use a non-invasive procedure, e.g., clipper

• Skin preparation with antiseptic

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Basic Recommendations for Prevention – Preoperative - 2• Surgical scrub with antiseptic (can be water-less);

nail cleaner • No brushes

• Exclude personnel with infections• Prophylactic antibiotics• Determine the level of experience required for

surgeons in complex surgeries

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Surgical hand scrub/hand rub

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Basic Recommendations for Prevention – Intraoperative - 1• Surgical checklist• Limit the duration of the procedure• Validate Sterilisation

• No flash sterilisation routinely

• Sterile gloves • Water-repellent gowns and drapes, mask, cap• Positive pressure ventilation (20 changes per hour)

• Filter air

• Doors closed

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Basic Recommendations for Prevention – Intraoperative - 2• Restrict entrance and movements• Asepsis in interventions and invasive procedures• Handle of tissue gently• Drains only if is necessary

• Remove as soon as possible

• Normothermia• Temperature between 36.5 and 37°C

• Normoglycaemia• <200 mg/dL

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Basic Recommendations for Prevention – Intraoperative - 3• Avoid artificial nails among surgical team• Screening and decolonisation of carriers of S.

aureus in high-risk patients • No special procedures after contaminated or

dirty operations• No over-shoes and tacky mats

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Basic Recommendations for Prevention - Postoperative

• Don’t touch the wound unless necessary• Review daily the necessity of continuing drains

and take out when no necessary• Surveillance system for SSI with risk

classifications • Post-discharge surveillance for ambulatory

surgery or short hospital stay

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Minimal requirements for the prevention of SSIs• Do not remove hair unless necessary• Glycaemia control in cardiac and vascular surgery• Antiseptic for skin preparation • Surgical scrub with antiseptic• Prophylactic antimicrobial• Validate sterilisation• Asepsis in interventions or invasive procedures• Surveillance with standard definitions and risk

classification

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Summary

• SSI development is multifactorial• There are strategies like surgical techniques, skin

preparation, and the timing and method of wound closure that influence it

• Antibiotic prophylaxis may have a positive impact in certain types of surgery

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References

• Galway UA, Parker BM, Borkowski RG. Prevention of Postoperative Surgical Site Infections. International Anes Clinics 2009; 47(4): 37–53.

• Mangram, AJ, et al. Guideline for Prevention of Surgical Site Infection, 1999. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250-278.

• Hranjec T, Swenson BR, Sawyer RG. Surgical site infection prevention: how we do it. (Report). Surg Infections 2010; 11 (3): 289-294.

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References• Ercole FF, et al. Applicability of the national nosocomial

infections surveillance system risk index for the prediction of surgical site infections: a review. Braz J Infect Dis 2007;11(1):134-41.

• Edwards JR, Horan TC. Risk-Adjusted Comparisons. IN: APIC Text of Infection Control and Epidemiology. 3rd ed. Association for Professionalsin Infection Control and Epidemiology, Inc. Washington, DC. 2009: 7-1 to 7-7.

• Haynes AB, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med 2009; 360 (5): 91–99. Checklist at http://whqlibdoc.who.int/ publications/2009/9789241598590_eng_Checklist.pdf

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Further reading• Potenza B, et al. Lessons learned from the institution of the

Surgical Care Improvement Project at a teaching medical center. Am J Surg 2009; 198(6):881-8.

• Awad SS, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg 2009; 198(5):607-10.

• Tom TS, Kruse MW, Reichman RT. Update: Methicillin-resistant Staphylococcus aureus screening and decolonization in cardiac surgery. Ann Thorac Surg 2009; 88(2):695-702.

• Akins PT, et al. Perioperative management of neurosurgical patients with methicillin resistant Staphylococcus aureus. J Neurosurg 2010; 112(2):354-61.

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Web sites• CDC/NHSN Surveillance Definition of Healthcare-Associated

Infection and Criteria for Specific Types of Infections in the Acute Care Setting –US. http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf

• Institute for Healthcare Improvement (US). http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/

• National Nosocomial Infection Program. Ministry of Health Chile. www.minsal.cl

• Surgical Site Infections – National Healthcare Safety Network, US. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

• Surgical Site Infection Surveillance Service (UK). http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SurgicalSiteInfectionSurveillanceService/

• WHO - Safe Surgery Saves Lives. http://www.who.int/patientsafety/safesurgery/en/index.html

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Quiz1. A key in a surveillance system for SSI is to have risk

stratification of the patients included. T/F?2. Which of the following is a risk factor for SSI?

a) Controlled diabetesb) Type of suturec) Breaks in the aseptic technique during surgeryd) Design of the operating room table

3. Which statement regarding antimicrobial prophylaxis is correct?

a) In all cases one dose is enough b) Has shown reduction in SSI in selected surgeriesc) Must be used for more than 48 hrs. after the surgeryd) All the available drugs are the same

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International Federation of Infection Control• IFIC’s mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .

• The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.

• For more information go to http://theific.org/

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