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Awareness to SurgicalSite InfectionTeddy O.H. Prasetyono
I.C.T.E.C(Indonesian Clinical Training and Education Center)
RSCM/ FKUI
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Disclosure
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Wound Microbiology
Wounds prone to potential infection, butnot always infected
Stages of condition related to the
existance of microbes:
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Chronic wound is always contaminated
1. Contaminated
2. Colonized
3. Infected
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Colonized wound
Normal flora grows without any
clinical sign and symptoms
Infected wound
Bacteria is growing fast with clinical
sign of tissue destruction
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Infection is tissue destructive and
prevents wound healing
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By time, normal flora will be
substituted by the existence of
anaerobic bacteria and even
poly-microbes
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Cut off point of infection is
CFU > 106 per gram tissue
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Infection depends on
a. Quantity of bacteria (Enterococcusand Candida need to be many, but other solitaire specific
bacteria will be dangerous
b. Potential (virulensi)(those producehyaluronidase, toxin)
c. Host resistance (depends on local and systemicfactors)
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bacterial balancebiofilms
hostresistance
bacterial quantityand
virulence
Sibbald et al (2000) Dow (2001)
Determinants for infection
always consider any underlying pathology
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SEMMELWEIS
mortality and puerperal sepsis
Hand washing before delivery:
1846 11.4%
1848 1.3%
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SURGICAL SITE INFECTION
CDC defines as: An infection that occurs at an incision site, or
any part of the anatomy that was opened or
manipulated during the procedure
Occurs within 30 days after surgery, or within1 year in the presence of an implant.
The data
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SSI
Can be as high as 15% (of HAI)Depends on indications, site, approach,
and instrumentation
Roy MC, Perl TM. Basics of surgical site infections surveillance. Infect Control Hosp Epidemiol.
1997; 18: 659-68.
Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, et al. risk factors for surgicalsite infection following orthopedic spinal operations. J Bone Joint Surg Am. 2008; 90A: 62-9.
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Classification of SSI
According to anatomical locationand pathophysiological changes
Involving skin, subcutaneoustissue, and deep soft tissue
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of surgical siteinfections, 1992: a modification of CDC definitions of surgical wound infection. Infect Control Hosp
Epidemiol. 1992;13: 606-8.
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Classification of SSI
Superficial incisional SSIDeep incisional SSIOrgan space SSI
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Superficial SSI
Within 30 days, involving skin or subcutaneoustissue
Plus one of the following Purulent drainage Organism isolated from culture At least one: pain, swelling, redness, heat,
incisions is deliberately opened
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Superficial SSI
The following conditions are not SSI Stitch abscesses (minimal inflammation and
discharge confined to the points of suturepenetration)
Infection of an episiotomy or neonatalcircumcision
Infected burn wound
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Deep SSI
Within 30 days or 1 year related toimplants
Related to the procedureInvolved deep soft tissue, e.g. fascia,
muscle
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Deep SSI
Plus one of the following Purulent drainage from incision but not from
organ/space
Spontaneously dehisces or deliberatelyopened
Abscess or infection found on direct exam,histopathologic, or radiologic exam
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Organ space SSI
Organ space infection Occurs within 30 days or 1 year with implant Involves anatomic structures not opened or manipulated during the
operation and at least one of the following:
Purulent drainage from drain placed in space
Organisms isolated from fluid from space
Identification of abscess at subsequent procedure
Diagnosis by surgeon or physician
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Wound classification National Nosocomial Infections Surveillance
(NNIS) score (depends on wound class,
duration of surgery, ASA)
Patient-associated factors Procedure-associated risk factors
Risk Factors for SSI
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Consequences of SSI
Extended hospitalisation of the patient(9.8 days in Europe)
Readmission rates to hospital increased Increased care costs (for items such as
prescriptions); average 325/day
Gottrup F, Melling A, Hollander DA. An overview of surgical site infections:
aetiology, incidence, and risk factors. EWMA J. 2005; 5(2): 11-5.
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Consequences of SSI
Delayed on-going treatments
Decreased confidence in healthcaresetting from local population - auditresults in the public domain
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Signs of local infection
?
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Signs of local infection
Excessive amount of exudateSign of inflammation (rubor, kalor, dolor,
edema, nyeri)
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Barriers to Healing: Infected Wounds
Is the wound infected?Local Signs & Symptoms
nPainn
Periwound skin is reddenednPeriwound skin is warm in touchnPeriwound skin or limb is
oedematous
nPeriwound skin is indurated (hard)or macerated
nPurulent exudate (green,yellow,..)nExudate has a foul odour
Systemic Signs & Symptoms
nFevern
MalaisenIncreased white blood cell count* N.B. To suspect infection, most of
the local and systemic S&S listed
here need to be present. Reddened
periwound skin and fever alone may
be a sign of the inflammatory phase
of healing.
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Micro-biology specimen to be
taken in the form of sample oftissue or pus
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Antimicrobial Therapy
Wound Infection
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Non antibiotics orNon chemically
active agents
Antiseptics ?
Antibiotics
Discuss this . . .
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JenisAn(sep(k
Keterangan
PovidonIodinaqua)
Povidon iodin 10% b/v, kompleks
iodin&polivinilpirolidon- An8sep8kkulitpraoperasi- Dapatdigunakanuntukmukosa- Kontakyanglamaakanmenyebabkan
lukabakarkimiawi
- Ha8-ha8 jika digunakan pada pasiendenganriwayathipersensi8fitasiodin
Riwayatpenyakit8roid
RiwayatpenggunaanlithiumTinkturIodin
Iodin0,5%dalamisopropilalkohol70%
- An8sep8kkulitpraoperasi- Mudahterbakar- Mengandungpreparatiodin
An(sep(cs
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Chlorhexidinaqua
Chlorhexidinglukonat0,05%b/v
- An(sep(kpraoperasi- Larutan(dakstabil- Hanya untuk kulit luar, (dak untuk
mukosa
Chlorhexidinalkohol
Chlorhexidin glukonat 0,05% b/v dalam
isopropilalkohol70%
- An8sep8k praoperasi atau bahan pencucitangan
- Dapatterbakar- Hanyauntukkulitluar,8dakuntukmukosa
Chlorhexidin+cetrimid
Chlorhexidin glukonat 0,015% b/v dalam
cetrimidPhEur0,15%b/v
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chlorhexidine
polyhexamethylene aqueous and alcoholic biguanides
polyhexanide
povidone iodine aqueous and alcoholic
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triclosan aqueous and suture coating
hexachlorophane aqueous phenolic
cetrimide aqueous cationic
benzalkonium surfactant
We cant do without them
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Althoughreportsofresistance
arelimited,misuseandabuse
ofan8sep8csmustbe
avoided.
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Moisture control
Maintaining moistenvironment
Exudate management
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Donotdepend
onlyonan8sep8csforwoundtreatment!
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Antiseptic dressings
Reduce bioburden and impact ofbacteria on healing
Debridement with lower toxicity thanhypochlorites
Aid in infection control (act as a barrier?)
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Antiseptic dressings
Reduce infection and associated costs Action on biofilms can we define
them?
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Bacterial killing(resistance)
antibiotics are specific
.cell wall, nucleus, DNA
antiseptics are not
..all cell components
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Bacterial loadhas a direct impact on wound healing
The management of the bacterial load by either local
or systemic therapy is important in wound
management
An(bio(cs
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There is no existing evidence to
support the use of systemic
antimicrobial agents for chronic-wound healing
Meara SO, Cullum N, MajidM, Sheldon T. Systematic review of wound care
management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot
ulceraton. Health Tech Asses. 2000; 4(21)
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Conservative treatment, including
prolonged, culture-guided parenteral and
oral antibiotics, is successful without
amputation in a large proportion ofdiabetic patients admitted for a foot skin
ulcer or suspected osteomyelitis
Pittet D, Wyssa B, Herter-Claver C, Kursteiner K, Vaucher J, Lew D. Outcome
of diabetic foot infections treated conservatively. Arch Intern Med. 1996 Apr;
159: 851-6.
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The development of an8bio8cs during
the20thcenturymarkedthedeclineof
many former remedies, but the
emergence of an8bio8c resistantstrains of pathogens has led to the
needtofindalterna8vetreatments.
MRSA d HAI ( l SSI )
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MRSA and HAIs (mostly SSIs)
(caused by antibiotic abuse?)
Largest epidemic of modern times
HAIs cause 50,000 deaths/year
5-6 district general hospitals
7-8000 bacteraemias MRSA(UK by Leaper)
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Why do Patients Still Die of Infection?
Overuse of powerful antibiotics Mis-targeting of broad-spectrum empiric therapy Inadequate source control Delayed onset of therapy Increased incidence of side effects Few options for drug-resistant infections Increasing prevalence of resistant pathogens
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Micro-organisms causing SSI(all categories 2002-07; HPA England data)
MSSA 14%
Enterococcus spp 9%
CNS 9%
Enterobacteriaceae
21%
MRSA 25%
Acinetobacter spp.
1%
Other bacteria 6%
Pseudomonas 9%
Anaerobic bacilli 2%
Streptococcus spp.
3%
Anaerobic cocci 2%
Number of organism s = 4034
biofilm production
synergy opportunistscontaminants and
transients
host defence
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SSI care bundle
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Preoperative Phase
Give antibiotic prophylaxis to patients before:
clean surgery involving the placement of aprosthesis or implant
clean-contaminated surgery contaminated surgery dirty surgery (?)
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Consider single dose!
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Methods to reduce bacterial resistance
Outbreak management Terminal room cleaning
o In-service housekeepingo Utilization of check lists for cleaningo All surfaces (high touch surfaces, lights, equipment, walls, etc)
cleaned
Rupp ME.Infect Control Hosp Epidemiol2001;22:301-303
Falk PS.Infect Control Hosp Epidemiol2000;21:575-582
Sehulster LM, HICPAC Guidelines for Environmenatal Infection Control in Healthcare Settings
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Methods to reduce bacterial resistance
Outbreak management Terminal room cleaning
o Quaternary ammonium disinfecting solutionso Change of curtains
Contact isolationo Unit-wide isolation of all patients
Rupp ME.Infect Control Hosp Epidemiol2001;22:301-303
Falk PS.Infect Control Hosp Epidemiol2000;21:575-582
Sehulster LM, HICPAC Guidelines for Environmenatal Infection Control in Healthcare Settings
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I.C.T.E.CRSCM/ FKUI