Surgical Wounds and

Antimicrobial prophylaxis

Philip G. Murphy
Consultant in Medical Microbiology, AMNCH
Clinical Professor, TCD
philip.murphy@amnch.ie (ext 3919)

Humanity has three great enemies:

Fever, famine and war,
Of these by far the greatest,
By far the most terrible is fever.
William Osler
1849-1919

History
1862
1865
1866

Pasteur
Lister
Semmelweiss

1940s Antibiotic era

Today

?? Postantibiotic era

<2 %

Public Health Importance of Surgical

Site Infections
In U.S., >40 million inpatient surgical
procedures each year; 2-5% complicated by
surgical site infection
SSIs second most common nosocomial
infection (24% of all nosocomial infections)
Prolong hospital stay by 7.4 days
Cost $400-$2,600 per infection (TOTAL: $130$845 million/year)

Source of SSI Pathogens

Endogenous flora of the patient
Operating theater environment
Hospital personnel (MDs/RNs/staff)
Seeding of the operative site from distant focus
of infection (prosthetic device, implants)

Pathogenesis
Skin flora into wound margins / deep sites
Surgical risk factors eg haematoma,
ischaemia, prostheses
Host factors, eg diabetes, steroid Rx
Bacterial factors eg., innoculum, virulence
eg GNB + anerobes

Diagnosis

Rubour,(Redness)
Dolour, (pain, tenderness)
Tumour, (swelling)

Fever
CRP, ESR, WBC

SSI- Wound classifications

Superficial
Deep
Organ/space

Merely a flesh wound

Wound healing - stages

Primary Healing Occurring when a wound is

closed within a few hours of its creation. Wound
edges are surgically or mechanically approximated,
and collagen metabolism provides long-term
strength

Delayed Primary Healing Occurs when a poorly

delineated wound is left open to protect against
wound infection. The open wound allows for the
natural host defense to debride the wound before
closure.
Secondary Healing Occurs when an open full
thickness wound is allowed to close by wound
contraction and epithelialization.
Healing of Partial-Thickness Wounds Occurs
when a partial-thickness wound is closed primarily
by epithelialization. This wound healing involves the
superficial portion of the dermis. There is minimal
collagen deposition, and an absence of wound
contraction.

SSI Risk Factors

Age
Obesity
Diabetes
Malnutrition
Prolonged preoperative
stay
Infection at remote site
Systemic steroid use
Immunotherapy
Nicotine use

Hair removal/Shaving
Duration of surgery
Surgical technique
Haematoma
Necrosis
Foreign body
Presence of drains
Inappropriate use of
antimicrobial prophylaxis

SSI - Classification and Rates

Clean
- no intrinsic bacterial flora

<2 %

Clean / contaminated
- involving a viscus with bacterial flora

8%

Contaminated
- involves spillage of viscus content

15%

Dirty
- involves inflammation or viscus perforation
<30 days post-op
1 year orthopaedics

40%

Bacterial aetiology
CDC NNIS data

Microbiology of SSIs
1986-1989
(N=16,727)
Pseudomonas
aeruginosa
8%

Staphylococcus
aureus
17%

Enterococcus
spp.
8%

Escherichia
coli
10%

1990-1996
(N=17,671)
Pseudomonas Staphylococcus
aureus
aeruginosa
20%
8%
Enterococcus
spp.
12%

Coagulase neg.
staphylococci
12%

Escherichia
coli
8%

Coagulase neg.
staphylococci
14%

Bacteriology
UK Survey:
Staphylococci 40-45 %
GNB
40-45 %
other aerobes 6 %
anaerobes
5%
Specific surgery types have different rates:

Bacteriology
Staphylococci and skin flora in bone and cardiac
surgery
GNB in biliary surgery
Streptococci and anaerobes in gynae
Colonic surgery:
aerobic GNB
10 6-7 / G
Enterococci10 5-6 / G
Bacteroides 10 9-11 /G
anaerobic cocci
10 10 / G

PREVENTION
IS PRIMARY!
Protect patientsprotect healthcare personnel
promote quality healthcare!

Theatre environment

Theatre design

Min staff
20-30 air changes/ hr
Plenum flow
Positive pressure
HEPA filtration
Asepsis: hand hygiene
Clothing
THINK HYGIENE

 Pre-op:

Prevention 1

avoid antibiotics, minimise hospitalisation, treat remote infection,

decolonise Staph, avoid/delay shaving, chlorhexidine bath,
resolve
obesity/malnutrition, control smoking or diabetes

Intra-op:
Skin prep, aseptic technique, filtered air, antibiotic wound irrigation,
isolate clean / dirty surgical fields - trays, reglove & new instruments from
donor vein to CABG, minimise drains, separate drain wound minimise
dead space haematomas and devitalised tissue

Post-op:
minimise catheters & IV lines, maintain oxygenation hydration & nutrition

Prevention 2
Bowel preparation:
No irrigation, diets, or non- absorbable

antibiotics

Theatre design & technique:

workflow zoning, air flow, CSSD, restricted
staffing, aseptic technique etc.

Wound management
Dressing - no touch technique,
Drainage none or closed or vacuum drains if pus

Antibiotic prophylaxis - principles

First dose immediately pre-op

maximum of 3 doses or 24h period
Rarely > 24h
parenteral, PR
No non-absorbables
Rarely required in clean or clean/contaminated

Perioperative AntibioticsProphylactic
Prophylactic antibiotics should exist at time of contamination.
Clean- contaminated and Contaminated showed reduction
In clean only when Foreign Body is inserted
Preoperative, close to cutting time, long half- life, selected
against specific pathogens, 4-6 hours later, and for 2
postoperative doses
Colon surgery: Oral antibiotics, poorly absorbed; neomycinerythromycin along with mechanical preparation, and IV
systemic
Dirty: fascial closure, wet-to-dry dressing and delayed
primary closure in 4-5 days

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 incision):
3.8%
Postop AP (3-24 hrs after incision):
3.3%
Periop AP (< 3 hrs after incision):
1.4%
Preop AP (<2 hrs before incision):
0.6%
Classen, 1992 (NEJM 326:281-286)

Antibiotic prophylaxis dynamics

Time of administration

Bacterial load

Prophylaxis - specific
Indication Antibiotic Duration
above knee amputation
benzyl penicillin
1 dose
Cholecystectomy
cefuroxime 1 dose
Appendicectomy
metronidazole 3 doses
Colectomy
Cefuroxime + 3 doses
metronidazole
vaginal hysterectomy as above
as above
or augmentin
Prosthetic hip replacement cefuroxime 2 doses
Prosthetic heart valve cefuroxime or fluclox tid <48h
Vascular prosthesis as above
as above

Supplemental Perioperative O2
DESIGN: Randomized controlled trial, double
blind
POPULATION: Colorectal surgery (N=500)
INTERVENTION: 30% vs 80% inspired
oxygen during and up to hours after surgery
RESULTS: SSI incidence 5.2% (80% O2) vs
11.2% (30% O2), p=0.01

Greif, R, et al , NEJM, 2000

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
Shaving 24 hours before
Shaving >24 hours before

= 3.1% SSI rates

= 7.1% SSI rates
= 20% SSI rates

Surgical Attire
Scrub suits
Cap/hoods
Shoe covers
Masks
Gloves
Gowns

Instruments and infection control

CSSD

Parameters for Operating Room

Ventilation
Temperature:
68o-73oF, depending on normal ambient temp
Relative humidity:
30%-60%
Air movement:
from clean to less clean areas
Air changes:
>15 total per hour, (20 routine, 30 orthopaedic)
>3 outdoor air per hour

Surgical Technique

Removing devitalized tissue

Maintaining effective hemostasis
Gently handling tissues
Eradicating dead space
Avoiding inadvertent entries into a viscus
Using drains and suture material appropriately

Treatment

Most infection are superficial no antibiotics

If complicated - open, drain, debride, micro & Abx
Topical Vs systemic
Saline Vs disinfectant Vs antibiotic
Target organisms Vs culture
empirical Vs culture targeted
one drug Vs two
Remove all prostheses / implants
pus collection drainage

Surveillance

Infection Control Team

Link nurses
Databases
Early discharge, day surgery
Post discharge

Reading reference
The CDC NNIS 1999 guidance document
is the comprehensive reference,(23 pages) :
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf