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DINA APRILYA
SURGICAL SITE
INFECTION
BEKASI CITY
GENERAL HOSPITAL
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Topics of Discussion
Background
HAIs
Burden
Impact
Diagnosis
Definition SSI
SSI surgical wound classification
Risk Factors Epidemiological Triad
Agent
Host
Environment
Prevention Recommendation
Preoperative
Intraoperative
Postoperative
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Background: Health-Care Associated Infections

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Background -Burden
PATIENT
Mortality
quality of life
Hospital length of
stay cost
HOSPITAL
3
RD

PARTY
PAYERS
Murray, BW et al. Surgical Site Infection in Colorectal Surgery. American College of Surgeons. Elsevier 2010.
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Background - Impact
Burden-US
~300,000 SSIs/yr (17% of all HAI; second to UTI)
2%-5% of patients undergoing inpatient surgery
Mortality
3 % mortality
2-11 times higher risk of death
75% of deaths among patients with SSI are directly
attributable to SSI
Morbidity
long-term disabilities
Anderson DJ, etal. Strategies to prevent surgical site infections in acute care hospitals.Infect Control Hosp Epidemiol 2008;29:S51-S61
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Background : Impact
Length of Hospital Stay
~7-10 additional postoperative hospital days
Cost
$3000-$29,000/SSI depending on procedure & pathogen
Up to $10 billion annually
Most estimates are based on inpatient costs at time of
index operation and do not account for the additional
costs of rehospitalization, post-discharge outpatient
expenses, and long term disabilities
Anderson DJ, etal. Strategies to prevent surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;29:S51-S61 for individual references

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WORK UP DIAGNOSIS

Olsen, MA, et al. Risk Factors for Surgical Site Infection Following Orthopaedic Operations. J Bone Joint Surg Am. 2008; 90: 62-9
Suggestive of infection
Readmission diagnosis of
infection
Microbiological cultures of
speciments from the wound
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Suggestive of Infection
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DEFINITIONS CDC/NNIS
Olsen, MA, et al. Risk Factors for Surgical Site Infection Following Orthopaedic Operations. J Bone Joint Surg Am. 2008; 90: 62-9
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Superficial Incisional SSI
Infection occurs within 30 days after surgical procedure
AND
Involves only skin and subcutaneous tissue of the incision
AND
Patient has at least 1 of the following:
a. Purulent drainage from the superficial incision
b. Organism isolated from an aseptically-obtained culture of fluid or tissue
c. Superficial incision that is deliberately opened by a surgeon and is
culture positive or not cultured
and
Patient has at least one of the following signs or symptoms:
pain or tenderness, localized swelling, redness, heat
d. Diagnosis of superficial SSI by surgeon or attending physician
NHSN Patient Safety Manual, Chapter 9: SSI, p 9-13, January 2013
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Deep Incisional SSI

NHSN Patient Safety Manual, Chapter 9: SSI, p 9-13, January 2013
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Organ Space SSI

NHSN Patient Safety Manual, Chapter 9: SSI, p 9-13, January 2013
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Classification of Surgery Corellation with SSI
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Ortega et al
Increased rate of infection when advancing from clean to dirty
procedures and found wound classification to be a significant predictor
of superficial, deep, and organ/space surgical site infections by
multivariate analyses.
Mioton et al
The highest rate of organ/space surgical site infections dirty
procedures.
The highest rates of superficial and deep SSIs contaminated
operations.
Risk-adjusted multivariable regression model: wound classification was
not a significant predictor for superficial SSIs and organ/space SSIs.
Contaminated and dirty wound categories were significant independent
predictors of a deep SSI, associated with a nearly threefold increased
risk of a deep SSI


Mioton, LM et al.The Relationship between Preoperative Wound Classification and Postoperative Infection: A Multi-Institutional Analysis
of 15,289 Patients. Arch Plast Surg. 2013 September; 40(5): 522529.
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Murray, BW et al. Surgical Site Infection in Colorectal Surgery. American College of Surgeons. Elsevier 2010.
Agent
Host Environment
Disease
OPERATION ROOM
STERILIZATION
PREOPERATIVE
PREPARATIONS
BIOFILM FORMATION:
ANTIBIOTICS RESISTANCE
UNCONTROLABLE FACTOR:
AGE
CONTROABLE FACTORS:
GLUCOSE LEVEL
TEMPERATURE
OXYGEN CONCENTRATION
SMOKING
OBESITY
NUTRITIONAL STATUS
COEXISTANCE OF INFECTION
REDUCED INNATE IMMUNE
RESPONSE
John Gordon
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AGENT
Endogenous
Patient flora
skin
mucous membranes
GI tract
Seeding from a distant
focus of infection

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


Hidron AI, et.al., Infect Control Hosp Epidemiol 2008;29:996-1011
Hidron AI et.al., Infect Control Hosp Epidemiol 2009;30:107107(ERRATUM)
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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;30:107107(ERRATUM)
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Micro-organisms reported as causing SSI
(all orthopaedic categories) four years combined (April 2004 to March 2008)
Health Protection Agency. Fourth Report of the Mandatory Surveillance of Surgical Site Infection in Orthopaedic Surgery. April 2004
to March 2008. London: Health Protection Agency, November 2008.
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BIOFILM FORMATION
Deposition of
the
conditioning
film
Attachment
Growth and
bacterial
colonization
Biofilm
formation
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FREE LIVING CELLS (PLANKTONIC CELLS) HAVE DIFFERENT
PROPERTIES WITH CELLS LIVING IN A COMMUNITY (SESSILE CELLS)
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THE RACE FOR THE SURFACE
Anthony Gristina 1987
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MECHANISM OF ANTIBIOTIC RESISTANCE IN BIOFILM

Failure to
penetrate biofilm
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MECHANISM OF ANTIBIOTIC RESISTANCE IN BIOFILM

Failure to penetrate
the biofilm
Slow growth: increased antibiotic resistance
Heterogeneity:
different level of
resistance
Quorum sensing and antibiotic
resistance
Efflux pump: extrudes antibiotics increased resistance
Antibiotic Resistance of Bacteria in Biofilms Stewart P.S. Lancet 2001; 358:135
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HOST AND ENVIRONMENT
Hyperglicemia and Diabetes
Obese
Ciggarete smoking
Age, nutritional status, coexistence infections
Suboptimal timing and/or dose of Antibiotic prophylactic
Surgical site,size, number, approaches, duration
Transfusion, excessive amounts of crystalloids
Participation of 2 or more surgical residents longer
surgical duration
Oxigen tension, Temperature
Drain utilization


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Obese-
SSI
Comorbidity
with DM
oxygen
tension
impaired tissue
penetration of
perioperative
antibiotics
prolonged
operative times
operative blood
loss
Diminished
immune function
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Smoking
vasoconstriction
reduction in the oxygen tension
in wounds
Neutrophils rapidly lose their
ability to kill bacteria below a
tissue Po2 of about 20 to 40
mm Hg
host defence
increases the incidence and
severity of infections in humans
excessive
amounts of
crystalloids
Hypothermia
generalized
vasoconstriction
decreases
subcutaneous blood
flow and oxygen
tension
Blood
transfusion
alterations of a large
number of immunologic
mechanisms : the most
important of which may be
macrophage functions
adverse effects on
antibody and cell-
mediated
immune and cytokine
regulation
Alexander JW et al.Updated Recommendations for Control of Surgical Site Infections . Annals of Surgery. Williams & Wilkins 2011
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COMPONENT OF CIGARETTE SMOKE?
Hydroxyquinone:
Decrease of IL-1, IL-2, IFN-, TNF- (macrophage)
Hydroxyquinone and catechol:
immunosuppresive
Decrease of lymphocyte proliferation
Acrolein:
Decrease of IL-8 and human defensin-2 production

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THE EFFECTS OF SMOKING OF IMMUNE CELLS FUNCTION

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Cigarette
smoking
Surfactan
Proteins
Alveolar
macrophage
T-Cell
PMNs
Altered
Signalling
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PREVENTION RECOMENDATIONS
CDC
Centers for Disease
Control
NICE
National Nosocomial
Infections Surveillance
National Institute for
Health-care Excellence
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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
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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 (continued)

Skin Prep
Use appropriate antiseptic agent and technique for skin preparation
Preoperative showering with chlorhexidine within a few hours of the
operation and the night before has been done and preoperative cleansing
of the operative site with a chlorexidine-impregnated cloth just before
entering the operating room.
Maintain immediate postoperative normothermia
Core temperature has been maintained at 36C or higher
throughout the perioperative period.
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
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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)*
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Prevention Strategies: Supplemental
Preoperative


Nasal screen for Staphylococcus aureus on patients
undergoing
Elective cardiac surgery, orthopedic, neurosurgery procedures with
implants
Decolonize carriers with mupirocin prior to surgery
Screen preoperative blood glucose levels and maintain
tight glucose control post-op day 1 and 2 in patients
undergoing select elective procedures
i.e., arthroplasties, spinal fusions, etc.
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Prevention Strategies: Supplemental
Perioperative
Redose antibiotic at 3 hr intervals in procedures with duration
>3 hours
Adjust antimicrobial prophylaxis dose for patients who are
obese (body mass index >30)
Use at least 50% fraction of inspired oxygen intraoperatively
and immediately postoperatively in select procedure(s)
Perform surveillance for SSI
Feedback surgeon-specific infection rates
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Prevention Strategies: Supplemental
Postoperative
Feedback of surgeon specific infection rates.
Education to patient
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Additional..
Transfusion of blood products has been limited.
Patients have stopped smoking for at least 4 weeks before operation for highly
elective procedures, such as abdominoplasty.
Gowns and drapeshave been used which prevent liquid penetration
All members of the operative team have double gloved and changed gloves
when any perforation is identified.
Antimicrobial incise drape has been used at operative sites where it is
technically feasible to get good adherence to the skin.
Minimal trauma to the wound itself by gentle handling of tissues and limited use
of electrocautery has been accomplished and all devitalized tissue has been
removed
Suture material has been selected which resists infection.
Dead spaces have been obliterated, where possible.
Conduit drains and drainage through a working incision have not been used.
Delayed primary closure in highly contaminated wounds
Alexander JW et al.Updated Recommendations for Control of Surgical Site Infections . Annals of Surgery. Williams & Wilkins 2011
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Management
Wound Care
Debridement +/- Drain
Wound dressing
VAC
Wound Closure
Medicines
Antibiotics
Supportive
HBO
Lymphatic massage
Controlling underlying disease and vascular problem
Stop smoking
Glucose control
Blood pressure control
Correcting Anemia
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Diagnosis
Wound bed Preparation
Exudate control Necrotic tissue removal Bacterial control
Absorbing products Debridement Antibiotic
Graft Secondary Primary Flap
Prepared wound bed
Healed Wound
Wound Closure
1
2
3
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DEBRIDEMENT
1. Surgical Debridement
2. Mechanical Debridement
3. Autolytic Debridement
4. Enzymatic Debridement
5. Biological Debridement
6. USG dan hydrosurgery


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Wound Dressing
Foam
Calcium
alginates
Antimicrobial
dressing
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Vacuum Assisted Closure (VAC)
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PPGD 2013 - RSUD Kota Bekasi
1
2
Skin graft 3
Skin Flap 4
Wound Closure

Secondary healing
Primary Closure
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