PROPOSAL FOR A PROJECT IN CERTIFICATE PROGRAM IN

HOSPITAL INFECTION CONTROL.

TITLE:
RISK FACTORS INFLUENCING DEVELOPMENT OF SURGICAL SITE
INFECTION IN CARDIAC PATIENTS.

NAME:
DR DAVID B IDOWU,
DEPARTMENT OF CARDIAC SURGERY,
INSTITUTES OF CARDIOVASCULAR DISEASES,
MADRAS MEDICAL MISSION,
CHENNAI.

DATE:
OCTOBER 2017

SUPERVISORS:
DR ANBARASU MOHAN RAJ
DR ANUSHA ROHIT
PROBLEM STATEMENT
Surgical site infection (SSI) is a waiting disaster that occurs amidst favourable risk factors. It is a
Hospital Acquired infection and a complication of cardiac surgery that generates increased
costs and longer hospital stays in comparison with patients without complication (3).
SSI has continued to be a major challenge to healthcare institution, and a leading cause of
hospital acquired infection in income-poor setting and second most common cause of HAI in
resource rich countries. (5)

INTRODUCTION
Surgical interventions, either curative or palliative; radical or conservative have evolved over the
years as a global acceptable modality of treatment, with its consequent morbidity and mortality.
SSI is a dreaded ordeal not just for the patient but the Surgeon and healthcare management. It
negatively impacts the patient causing financial, emotional, functional and occupational burden
on the patient and the family.
In the past few years, important advances have been achieved in the field that may have had an
impact on the reduction of SSI. These include, more effective surgical sterilization procedures,
laminar flow, high efficiency particulate absorbing (HEPA) filters, ultraviolent irradiation, air
renewal, humidity control, differential temperature and air pressure, particulate count, surface
colony count, Antibiotics prophylaxis. (1) SSI remains a substantial cause of morbidity,
prolonged hospitalization and death. (2)
The documented incidence of SSI in terms of cumulative incidence varies from 0.6% to 3%. (3)
The incidence of sternal wound infection reported by different studies ranges from 0.9% to
20.0%, with numerous factors related to the patient, the surgical procedure and the clinical
environment contributing to the overall risk of infection. Reported rates also depend on the
definition of infection, as well as the duration and method of follow-up. (4)

Many risk factors identified as influencing the development of SSI have all been classified into
three categories:

• Factors that increase Endogenous Microbial contamination of the surgical wound.

• Factors that increase Exogenous Microbial contamination of the surgical wound.
• Factors which diminish host immunity both local and systemic.
Some of the specific risk factors mentioned in literature review include: age, gender, body mass
index, diabetes mellitus, chronic obstructive pulmonary disease, obesity, previous cardiac
surgery, use of antibiotics or steroid, after admission to the hospital, preoperative renal failure,
urgency of surgery, a bilateral internal mammary artery procedure, technical errors of sternal
incision, internal mammary arterial graft, blood transfusion, reexploration, inotropic support,
prolonged intubation, use of an aortic balloon, duration on cardiopulmonary bypass, and
postoperative dialysis. However, the risk factors for SSI after sternotomy remain unclear. (3)
AIMS AND OBJECTIVES
The aim of this study is to assess the rates of and risk factors for SSI, including sternal wound
and leg SSI, after cardiac surgery at The Madras Medical Mission (MMM), Chennai, India.
Most of the cardiac procedures performed in this tertiary healthcare facility include coronary
artery bypass grafting (CABG), valve repairs and replacements and congenital heart surgeries.
All these procedures involve making anterior chest incision through the sternum. However, in
addition to the chest incision, there is one more chance of incurring an SSI for bypass patients,
because of the harvesting of the saphenous vein from the leg. (3)
It will be assumed that SSI, including sternal SSI and leg SSI, are related to patient and surgical
characteristics (especially the time factor in each process) and characteristics of medical care
personnel at the pre-, intra-, and postoperative stages. (3)

MATERIALS AND METHODS.

WOUND CLASSIFICATION:
The risk of infection also varies by type of surgical incision site. For example, invasive
procedures that penetrate bacteria-laden body sites, especially the bowel, are more prone to
infection. The traditional wound classification system designed by the Center for Disease
Control and Prevention (CDC) stratifies the increased likelihood and extent of bacterial
contamination during the surgical procedure into four separate classes of procedures: (6)

Clean wounds
The wound is considered to be clean when the operative procedure does not enter into a
normally colonized viscous or lumen of the body. SSI rates in this class of procedures are less
than 2%, depending upon clinical variables, and often originate from contaminants in the OR
environment and from the surgical team or most commonly from skin. (6)

Clean-contaminated wounds
A site is considered to be clean-contaminated when the operative procedure enters into a
colonized viscous or cavity of the body, but under elective and controlled circumstances. SSI
rates in this class of procedures range from 4% to 10%. (6)

Contaminated wounds
When gross contamination is present but no infection is obvious, a surgical site is considered to
be contaminated. As with clean-contaminated procedures, the contaminants are bacteria that
are introduced by soilage of the surgical field. SSI rates in this class of procedures can exceed
20%.(6)

Dirty wounds
If active infection is already present in the surgical site, it is considered to be a dirty wound.
Pathogens of the active infection as well as unusual pathogens will likely be encountered. SSI
rates in this class of procedures can exceed 40%. (6)
CDC SURGICAL SITE INFECTION DEFINITIONS

Wound infection is most commonly characterized by the classic signs of redness (rubor), pain
(dolor), swelling (tumor), elevated incisional tissue temperature (calor) and systemic fever.
Ultimately, the wound is filled with necrotic tissue, neutrophils, bacteria and proteinaceous fluid
that together constitute pus.
SSIs are separated into three types, depending on the depth of infection penetration into the
wound: superficial incisional, deep incisional and organ/space. An infection must occur within 30
days after surgery to be classified as an SSI; however, if the surgery includes an implanted
device or prosthesis, then the infection window extends out to one year. Evidence of incisional
pus, cellulitis, deliberate incision and drainage of surgical site and/or diagnosis of SSI by
physician are also required for conformance with the definition.

The figure below illustrates the three types of SSI.

Medical Illustration Copyright © 2006 Nucleus Medical Art, All rights reserved.
www.nucleusinc.com
STUDY DESIGN
This will be an observational prospective cohort study to assess the rate of SSI after Cardiac
surgery MMM, Chennai.
Within this cohort, the patient will be classified into 4 groups: sternal SSI, Leg SSI, Double SSI
(both sternal and leg), and No SSI (Control) for evaluation of SSI risk factors.

STUDY POPULATION
The prospective enrollee are the patients being planned for and will undergo cardiac surgery
during the study period. They are usually admitted few days before the procedure for final
clinical evaluation and investigation workup.

CASE CRITERIA
The patient enrollment will begin at admission into Cardiac wards, data will be collected on risk
factor throughout their hospitalization.
Sternal SSI will be defined according to SSI criteria of United States CDC. Infection that occurs
within 30days after surgery will be included, it can be any of the following types:
• Superficial incisional (infection skin and subcutaneous tissue of sternal area)
• Deep incisional (infection involving the sternum)
• Organ / space (site specific location such as Mediastinitis)
• Leg SSI will be defined as redness, swelling, increased pain, excessive bleeding or
discharge at incision site among patient who will undergo CABG.

RISK FACTORS
Potential risk factors for sternal SSI will be classified into three groups according to stage
(preoperative, intraoperative, and postoperative).
Preoperative potential risk factors include demographic factor (age, gender, height, weight, body
mass index, date of admission, wards, smoking and alcohol), and factors pertaining to medical
history (obesity, chronic obstructive airway disease, diabetes mellitus, hypertension, hypo-/-
hyperthyroidism, renal failure, cerebrovascular accident (CVA) / epilepsy, Malnutrition)
Intraoperative potential risk factors are skin preparation (shaving and antiseptic wash), time of
prophylactic antibiotics administration, use of adhensive drapes, time of incision, surgical team,
surgical procedure, cardiopulmonary bypass (CPB) time, aortic cross-clamping time, duration of
surgery, local use of antimicrobial agent before closure, use of second dose of antibiotics.
Postoperative potential factors in view are duration of endotrachea intubation, serum protein
(malnutrition), reintubation, reexploration, blood glucose, blood transfusion
SAMPLE SIZE
An average of 120 to 150 cases of Coronary Artery bypass grafting, valvar and congenital heart
surgeries are done on monthly basis.
A sample size of 90-100 cases will be enrolled for this study.

EXPECTED RESULT
It is expected that the rates and risk factors of SSI in cardiac patients will be calculated and
validated with previous studies in the hospital.
The result can also be compared with the national and regional data.
REFERENCE
1. Alfonso-Sanchez JL, Martinez IM, Martín-Moreno JM, González RS, Botía F. Analyzing
the risk factors influencing surgical site infections: the site of environmental factors.
Canadian Journal of Surgery. 2017 Jun;60(3):155
2. Module 4 hospital infection control.
3. Ku CH, Ku SL, Yin JC, Lee AJ. Risk factors for sternal and leg surgical site infections
after cardiac surgery in Taiwan. American journal of epidemiology. 2005 Apr
1;161(7):661-71.
4. Dohmen PM, Gabbieri D, Weymann A, Linneweber J, Konertz W. Reduction in surgical
site infection in patients treated with microbial sealant prior to coronary artery bypass
graft surgery: a case–control study. Journal of Hospital Infection. 2009 Jun 30;72(2):119-
26.
5. Tartari E, Weterings V, Gastmeier P, Baño JR, Widmer A, Kluytmans J, Voss A. Patient
engagement with surgical site infection prevention: an expert panel perspective.
Antimicrobial Resistance & Infection Control. 2017 May 12;6(1):45.
6. Pear SM. Patient risk factors and best practices for surgical site infection prevention. Manag
Infect Control. 2007 Mar;56.