SURGICAL SITE

INFECTIONS

Teguh Sarry Hartono

PPDS Mikrobiologi Klinik
Oktober 2010
Historical background
• Until the ends of the 19th cent., infection was
the greatest risk associated with any
surgical procedure.
•
• Increasing knowledge regarding relationship
between bacteria and infection, led to series
of discoveries and the development of
techniques that ultimately paved the way for
modern surgery.

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Historical background...........

•Pasteur studied the relationship between

bacteria and putrefaction.
•
•Lister recognized the role of bacterial in
surgical wound infections and in 1867
introduced
•
•
Historical background...........

•In 20th cent., the standarization of aseptic

practices in the operating room greatly
improved the safety of clean operative
procedures, but operating involving anatomic
structures with dense a endogenous that
cannot eliminate before surgery , such as
colon and rectum, continued to carry a very
high risk of infection.
•
•

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 Public Health Importance of Surgical Site
Infections
CDC (1999) :
•US : approx. 27 million surgical procedures / yearare performed each
year.
•National Nosocomial Infections Surveillance (NNIS) system reported :
•SSIs : 3rd most frequently reported nosocomial infection,
accounting for 14% - 16% of all nosocomial infections among
hospitalized patients.
•During 1986 to 1996, SSI surveillance reported 15,523 SSIs
following 593,344 operations (CDC, unpublished data).
•Among surgical patients, SSIs were the most common nosocomial
infection, accounting for 38% of all such infections, 2/3 were
confined to the incision , 1/3 involved organs or spaces accessed
during the operation.
•77% of the death of surgical patients with nosocomial were
reported to be related to the infection, and the majority (93%)
were serious infections involving organs or spaces accessed
during the operation.
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Mangram AJ. Guideline for prevention of surgical site infection, 1999. Infection control and hospital epidemiology. Vol.
20 No. 4. 1999
 • 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)
•

Pearson ML. Prevention of Surgical Site Infections: Considerations in Measuring

Effectiveness. Ppt presentation. of 46 6
www.fda.gov/ohrms/dockets/.../2005-4098S1_02_FDA-Pearson.pptAccessed on 9102010
Emerging Challenges

Challenges in detecting SSIs

•

• Lack of standardized methods for post-

discharge/outpatient surveillance
• Increased number of outpatient surgeries
• Shorter postoperative inpatient stays
•
•Antimicrobial Prophylaxis

• Increasing trend toward resistant organisms may

undermine the effectiveness of existing
recommendations for antimicrobial prophylaxis

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Criteria for defining SSIs (NNIS)

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Defining Surgical Site Infections
Superficial incisional
(skin or subcutaneous tissue)
•
•Infection ≤30 days after procedure and at least 1 of
the following:
–Purulent drainage from superficial lesion/organisms
isolated aseptically
–At least 1: pain/tenderness, swelling, redness, heat
–Superficial incision deliberately opened by surgeon
unless culture negative

•or SSI diagnosed by surgeon or attending physician

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Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission.9
Copyright © 1992 University of Chicago Press. All rights reserved.
Defining Surgical Site Infections (cont.)
Deep incisional
(deep soft tissue at incision site)
•
•Infection ≤30 days after procedure (no implant) or
≤1 year (with implant) plus at least 1 of of the following:
–Purulent drainage from deep in incision but not from
organ/space
–Spontaneous dehiscence or surgical opening of deep
incision with fever, pain, or tenderness
–Abscess or other evidence of infection involving deep
incision

•or SSI diagnosed by surgeon or attending physician

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Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. 10
Figure reproduced with permission.
Copyright © 1992 University of Chicago Press. All rights reserved.
Defining Surgical Site Infections (cont)
Organ/space
(any site other than incision)
•
•Infection ≤30 days after procedure (no implant) or
≤1 year (with implant) plus at least 1 of the following:
–Purulent drainage from a drain placed through a stab
wound into organ/space
–Organisms isolated from a culture of fluid or tissue
–Abscess or other evidence of infection involving the
organ/space found by histopathologic examination,
X-ray, or reoperation

•or SSI diagnosed by surgeon or attending physician

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Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. 11
Figure reproduced with permission.
Copyright © 1992 University of Chicago Press. All rights reserved.
Surgical Wound Classification

• Class 1 – Clean
• Uninfected operative wound, no inflammation
• Class II – Clean-Contaminated
• Alimentary tract (and others), under controlled conditions
without unusual contamination
• Class III – Contaminated
• Major breaks in sterile technique, eg, gross spillage from
the gastrointestinal tract
• Incisions encountering acute inflammation
• Class IV – Dirty-Infected
• Old traumatic wounds with dead tissue, infection,
perforated viscera
•

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Mangram AJ et al. Am J Infect Control. 1999;27:97–134.
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Pathogenesis
Pathogen Sources

• Endogenous
• Patient flora
• skin
• mucous membranes
• GI tract
• Seeding from a distant focus of infection

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Pathogen Sources
• Exogenous
• Surgical Personnel (surgeon and team)
• Soiled attire
• Breaks in aseptic technique
• Inadequate hand hygiene
• OR physical environment and ventilation
• Tools, equipment, materials brought to the operative field
•

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Pathogenesis

Virulence
Bacterial dose

Impaired
host resistance

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Pathogenesis.....

qIf a surgical site is contaminated with >105

microorganisms per gram of tissue, the risk of
SSI is markedly increased. However, the dose
of contaminating microorganisms required to
produce infection may be much lower when
foreign material is present at the site (i.e., 100
staphylococci per gram of tissue introduced on
silk sutures)

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Pathogenesis.....

qMicroorganisms may contain or produce toxins and

other substances that increase their ability to invade
a host, produce damage within the host, or survive
on or in host tissue. For example, many gram-
negative bacteria produce endotoxin, which
stimulates cytokine production. In turn, cytokines can
trigger the systemic inflammatory response
syndrome that sometimes leads to multiple system
organ failure.
q
qOne of the most common causes of multiple system
organ failure in modern surgical care is
intraabdominal infection.
q
q

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Pathogenesis.....

qSome bacterial surface components, notably

polysaccharide capsules, inhibit phagocytosis, a critical
and early host defense response to microbial
contamination.
qCertain strains of clostridia and streptococci produce potent
exotoxins that disrupt cell membranes or alter cellular
metabolism. A variety of icroorganisms,including gram-
positive bacteria such as coagulasenegative staphylococci,
produce glycocalyx and an associated component called
“slime,”which physically shields bacteria from phagocytes
or inhibits the binding or penetration of antimicrobial
agents.
qAlthough these and other virulence factors are well defined,
their mechanistic relationship to SSI development has not
been fully determined.
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Microbiology
of SSIs

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 1986-1989 1990-1996
(N=16,727) (N=17,671)
PseudomonasStaphylococcus PseudomonasStaphylococcus
aeruginosa aureus aeruginosa aureus
8% 17% 8% 20%

Enterococcus Enterococcus
spp. spp.
8% 12%

Escherichia Coagulase neg. Escherichia Coagulase neg.

coli staphylococci coli staphylococci
10% 12% 8% 14%

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 Infections, %
St
ap

10%
15%
20%

0%
5%
hy
lo
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au cc
C re us
oa us
gu
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ap se
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En cc ve
us
te
ro
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us
sp
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Es
ch

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NNIS Report. Am J Infect Control. 1996;24:380–388.
Major Pathogens in SSI

er
ic
hi
a
co
li
Ps
eu
ae do
ru mo
gi n
no as
En sa
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er
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23
Microbiology of SSIs
• Unusual pathogens
• • Rhizopus oryzea - elastoplast adhesive
bandage
• • Clostridium perfringens - elastic bandages
• • Rhodococcus bronchialis - colonized health
care personnel
• • Legionella dumoffii and pneumophila - tap
water
• • Pseudomonas multivorans - disinfectant
solution
•
• Cluster of unusual SSI pathogens  formal
epidemiologic investigation
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Organisms Causing SSI
January 2006-October 2007

•Staphylococcus aureus 30.0%

•Coagulase-negative staphylococci 13.7%
•Enterococcus spp. 11.2%
•Escherichia coli 9.6%
•Pseudomonas aeruginosa 5.6%
•Enterobacter spp 4.2%
•Klebsiella pneumoniae 3.0%
•Candida spp. 2.0%
•Klebsiella oxytoca 0.7%
•Acinetobacter baumannii 0.6%
•

• N=7,025
•
Hidron AI, et.al., Infect Control Hosp Epidemiol 2008;29:996-1011
Hidron AI et.al., Infect Control Hosp Epidemiol 2009;30:107–107(ERRATUM)
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SSI Risk Factors

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SENIC Risk Index

• Abdominal operation
• Operation greater •Risk of Infection
•0 1%
than 2 hours
•1 3.6%
• Class III or IV
surgical wounds •2 9%
• Three or more •3 17%
diagnosis at time •4 27%
of discharge

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 NNIS Risk Index
1 Normal healthy patient
2• ASAMild systemic
score abovedisease
2
3• Level of systemic disease
Severe
contamination
4 Life threatening systemic disease
• Operative time
5 Moribund
greater patient
than 75 with less than 24 hr life
expectancy
percentile of
normal
6 Organ donation

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Important Modifiable Risk Factors

• Antimicrobial prophylaxis
• Inappropriate choice (procedure specific)
• Improper timing (pre-incision dose)
• Inadequate dose based on body mass index,
procedures >3h, or increased blood loss
• Skin or site preparation ineffective
• Removal of hair with razors
• Colorectal procedures
• Inadequate bowel prep/antibiotics
• Improper intraoperative temperature
regulation
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Additional Modifiable Risk Factors
•

• Excessive OR traffic
• Inadequate wound dressing protocol
• Improper glucose control
• Colonization with preexisting microorganisms
• Inadequate intraoperative oxygen levels

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 Prevention Strategies

• Core Strategies • Supplemental

• High levels of Strategies
scientific • Some scientific
evidence evidence
• Demonstrated • Variable levels
feasibility of feasibility
• •

*The Collaborative should at a minimum include core prevention strategies. Supplemental prevention
strategies also may be used. Most core and supplemental strategies are based on HICPAC
guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*)
after the strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac

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 Prevention Strategies: Core
Preoperative Measures •

• Administer antimicrobial prophylaxis in

accordance with evidence based standards and
guidelines
• Administer within 1 hour prior to incision*
• 2hr for vancomycin and fluoroquinolones
• Select appropriate agents on basis of
• Surgical procedure
• Most common SSI pathogens for the
procedure
• Published recommendations
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National
•

Quality Measures. Surg Infect 2008;9(6):579-84.

•
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 Prevention Strategies: Core
Preoperative Measures
•

• Remote infections-whenever possible:

• Identify and treat before elective operation
• Postpone operation until infection has resolved
•
• Do not remove hair at the operative site unless it
will interfere with the operation; do not use
razors
• If necessary, remove by clipping or by use of a
depilatory agent
•
•

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 Prevention Strategies: Core
Preoperative Measures
• Skin Prep
• Use appropriate antiseptic agent and technique for
skin preparation
•
• Maintain immediate postoperative
normothermia*
•
• Colorectal surgery patients
• Mechanically prepare the colon (Enemas, cathartic
agents)
• Administer non-absorbable oral antimicrobial
agents in divided doses on the day before the
operation
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National
Quality Measures. Surg Infect 2008;9(6):579-84.

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Prevention Strategies: Core
Intraoperative Measures

• Operating Room (OR) Traffic

• Keep OR doors closed during surgery except as
needed for passage of equipment, personnel,
and the patient
•

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 Prevention Strategies: Core
Postoperative Measures

• Surgical Wound Dressing

• Protect primary closure incisions with sterile dressing
for 24-48 hrs post-op
•

• Control blood glucose level during the

immediate post-operative period (cardiac)*
• Measure blood glucose level at 6AM on POD#1 and
#2 with procedure day = POD#0
• Maintain post-op blood glucose level at <200mg/dL
•
• Discontinue antibiotics within 24hrs after
surgery end time (48hrs for cardiac)*
• *Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National
• Quality Measures. Surg Infect 2008;9(6):579-84.
•

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 Prevention Strategies: Supplemental
Preoperative •

• Nasal screen and decolonize only

Staphylococcus aureus carriers undergoing
elective cardiac and other procedures (i.e.,
orthopaedic, neurosurgery procedures with
implants) with preoperative mupirocin
therapy*Bode LGM, etal. Preventing SSI in nasal carriers of Staph aureus. NEJM
2010;362:9-17
• Screen preoperative blood glucose levels and
maintain tight glucose control POD#1 and
POD#2 in patients undergoing select elective
procedures (e.g., arthroplasties, spinal
fusions)*
NOTE:
• These supplemental strategies are not part of the 1999 HICPAC Guideline for Prevention of
Surgical Site Infections

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 Prevention Strategies: Supplemental
Perioperative
•

• Redose antibiotic at the 3 hr interval in

procedures with duration >3hrs (* See exceptions to
this recommendation in*EngelmanR, et al. The Society of Thoracic Surgeons
Practice Guideline Series:Antibiotic Prophylaxis in Cardica Surgery, Part
II:Antibiotic Choice. Ann Thor Surg 2007;83:1569-76
• Adjust antimicrobial prophylaxis dose for
obese patients (body mass index
>30)* Anderson DJ, Kaye KS, ClassenD, et al. Strategies to prevent surgical
site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29
(Suppl 1):S51-S61
• Use at least 50% fraction of inspired
oxygen intraoperatively and immediately
postoperatively in select
procedure(s)* Maragakis LL, Cosgrove SE, Martinez EA, et al.
Intraoperativefraction of inspired oxygen is a modifiable risk factor for surgical site
infection after spinal surgery. Anesthesiology 2009;110:556-562. and
• Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative
oxygen fraction on surgical site infection and pulmonary complications after abdominal
NOTE: Thesesurgery: The PROXI
supplemental randomized
strategies clinical
are not part oftrial.
theJAMA 2009;302:1543-1550.
1999 HICPAC Guideline for Prevention of
•
Surgical Site Infections
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•
Prevention Strategies: Supplemental
Postoperative
• Feedback of surgeon specific infection rates.

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 Measurement: Surgical Care Improvement
Project (SCIP) Process Measures
Quality Indicator Numerator Denominator
Appropriate antibiotic Number of patients who All patients for whom
choice received the appropriate prophylactic antibiotics
prophylactic antibiotic are indicated
Appropriate timing of Number of patients who All patients for whom
prophylactic antibiotics received the prophylactic prophylactic antibiotics
antibiotic within 1hr prior are indicated
to incision (2hr:
Appropriate Vancomycin
Number or
of patients who All patients who received
discontinuation of Fluoroquinolones)
received prophylactic prophylactic antibiotics
antibiotics antibiotics and had them
discontinued in 24 h (48h
cardiac)

Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP):
of 462008;9(6):579-84.
Evolution of National Quality Measures. Surg Infect 40
 Measurement: Surgical Care Improvement
Project (SCIP) Process Measures (cont.)

Quality Indicator Numerator Denominator

Appropriate hair removal Number of patients who All surgical patients
did not have hair
removed or who had hair
Normothermia removed
Number ofwith clippers
patients with All surgical patients
postoperative
temperature ≥36.0oC
Glucose control Number of cardiac Patients undergoing
surgery patients with cardiac surgery
glucose control at 6AM
POD1 and POD2
(operation = POD0)

Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP):
of 462008;9(6):579-84.
Evolution of National Quality Measures. Surg Infect 41
Antimicrobial Prophylaxis for Surgery

Clinical Infectious Diseases 2004; 38:1706–15

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Always check for aller
Administer medication

Category
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References

1.Delinger EP. Surgical Site Infections. In Jarvis WR. Bennett &

Bachman’s Hospital Infections. Lippincott William & Wilkins 2007
2.
3.Mangram AJ. Guideline for prevention of surgical site infection,
1999. Infection control and hospital epidemiology. Vol. 20 No. 4.
1999
4.
5.Pearson ML. Prevention of Surgical Site Infections: Considerations
in Measuring Effectiveness. Ppt presentation.
www.fda.gov/ohrms/dockets/.../2005-4098S1_02_FDA-Pearson.
pptAccessed on 9102010
6.
7.Barie PS. Controversies in Prevention of Surgical Site Infections
Ppt presentation.
http://www.acs-tr.com/ppt/Philip%20S.Barie%20Controversies%20in%20
Accessed on 9102010
8.
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4.
6.Torres SIB. Surgical Site Infection (SSI) Toolkit
Activity C: ELC Prevention Collaboratives.
www.cdc.gov/hai/ppt/SSItoolkit03242010.pptx Acessed on
9102010
7.
8.Bratzler DW, Houck PM. Antimicrobial Prophylaxis for Surgery: An
Advisory Statement from the National Surgical Infection
Prevention Project. Clinical Infectious Diseases 2004; 38:1706–
15
9.
10.Yakima Valley Memorial. Surgical Site Infection Collaborative.
http://www.100kliveswashington.org/SSICollaborative10-20-05.ppt
Accessed on 23092010
11.

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Thanks..........
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