Awareness to SSI

7/27/2019 Awareness to SSI

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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

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Awareness to SSI

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