Prevention of Surgical
Site Infections (SSI)
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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Learning objectives
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• 35-40 minutes
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Time involved
3
• One of the most important healthcare associated
infections
• 25% of all HAIs
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Background - 1
• 40% to 60% preventable
• High cost
• prolong hospital stay
• increase antimicrobial and laboratory costs
• require added health care interventions
4
• Sterilisation, aseptic technique, clean air,
and prophylaxis have reduced SSI
• The numbers are still high
• Important cause of morbidity and
mortality
• Multi-factorial
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Background - 2
• Difficult to determine the exact cause
• Higher in developing nations
5
• Patient risk factors
• Types of surgical procedures
• Operating room environment
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Factors that influence
transmission of infection
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Proven
Controversial
Uncontrolled Diabetes
Nutrition status
Smoking
Obesity especially in
orthopaedic and cardiac
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Patient risk factors
Coexisting remote
infection
Colonisation with
microorganisms
Length of preoperative
stay
Perioperative transfusion
7
• Colonisation of the operative site
• Antiseptic bath
• Skin antisepsis (consider clorhexidine)
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Operative Risk Factors - 1
• Colonisation of the surgical team
• Surgical scrub with antiseptic
• No artificial nails
• Preoperative shaving
• Infected or colonised surgical personnel
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• Duration of operation
• Contamination of the operative site
• Antimicrobial prophylaxis
• Foreign material in the surgical site
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Operative risk factors - 2
• sutures and drains
• Hypothermia
• Surgical technique
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• Operating room ventilation
• Number of people in OR
• Inanimate surfaces
• Inadequate sterilisation
• Surgical clothes, gloves and masks
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Environmental risk factors
10
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Ventilation system
11
• Shown to reduce SSI risk
• Post-discharge surveillance essential
• Should include
• Standard definitions
• Risk stratification
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Surveillance
• 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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• Based on a specific surgery
• Cholecystectomy, hernia repair, Caesarean section, hip
replacement
• Specific risk of patients
• Type of surgery
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Risk stratification
• Clean, clean-contaminated, contaminated, or dirty
• Compare the clean wound SSI rates among
different surgeons
• Patient index
• Standardised infection ratios
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• Identify and treat all infections
• Good control of diabetes
• Minimum hospital stay
• Do not remove hair preoperatively
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Basic Recommendations for
Prevention – Preoperative - 1
• If essential, use a non-invasive procedure, e.g., clipper
• Skin preparation with antiseptic
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• Surgical scrub with antiseptic (can be waterless); nail cleaner
• No brushes
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Basic Recommendations for
Prevention – Preoperative - 2
• 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
16
• Surgical checklist
• Limit the duration of the procedure
• Validate Sterilisation
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Basic Recommendations for
Prevention – Intraoperative - 1
• 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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• Restrict entrance and movements
• Asepsis in interventions and invasive procedures
• Handle of tissue gently
• Drains only if is necessary
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Basic Recommendations for
Prevention – Intraoperative - 2
• Remove as soon as possible
• Normothermia
• Temperature between 36.5 and 37°C
• Normoglycaemia
• <200 mg/dL
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• 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 – Intraoperative - 3
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• 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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Basic Recommendations for
Prevention - Postoperative
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• 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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Minimal requirements for the
prevention of SSIs
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• 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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Summary
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• 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.
December 1, 2013
References
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• 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
December 1, 2013
References
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• 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.
December 1, 2013
Further reading
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• 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_curren
t.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/Surg
icalSiteInfectionSurveillanceService/
• WHO - Safe Surgery Saves Lives.
http://www.who.int/patientsafety/safesurgery/en/index.html
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Web sites
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1.
2.
A key in a surveillance system for SSI is to have risk
stratification of the patients included. T/F?
Which of the following is a risk factor for SSI?
a)
b)
c)
d)
3.
Controlled diabetes
Type of suture
Breaks in the aseptic technique during surgery
Design of the operating room table
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Quiz
Which statement regarding antimicrobial prophylaxis is
correct?
a)
b)
c)
d)
In all cases one dose is enough
Has shown reduction in SSI in selected surgeries
Must be used for more than 48 hrs. after the surgery
All the available drugs are the same
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• 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/
December 1, 2013
International Federation of
Infection Control
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