Surgical Site

Infections(SSI)
Prepared by surgical nursing students

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Introduction
• Wound infection is most commonly characterized by the classic
signs of redness (rubor), pain (dolor), swelling (tumor),
elevated incisional tissue temperature (calor) and systemic
fever. Ultimately, the wound is filled with necrotic tissue,
neutrophils, bacteria and Proteinaceous fluid that together
constitute pus.

• SSI is define as the infection that occurs at the site of surgery

within 30 days of a surgery or within 1 year of a surgery if a
foreign body is implanted as part of the surgery

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Cont’d…
• SSl’s are infections of the tissues, organs or spaces exposed during
the performance of an invasive surgical procedure.

• Surgical site infections have been shown to compose up to 20% of all

of healthcare-associated infections. At least 5% of patients
undergoing a surgical procedure develop a surgical site infection.

• Surgical infections may arise in the surgical wound itself or in other

systems in the patient.

• They can be initiated not only by “damage” to the host but also by
changes in the host’s physiologic state.
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Causes
Common bacteria causing surgical infections:

1. Streptococci : Streptococcus pyogenes and Streptococcus faecalis.

2. Staphylococci : Staphylococcus aureus, MRSA, Staphylococcus epidermidis.
3. Clostridia: . Clostridium perfringens cause gas gangrene, and C. tetani causes tetanus,
Clostridium difficile is the cause of pseudomembranous colitis.
4. Aerobic gram-negative bacilli: Escherichia coli and Klebsiella spp.. Pseudomonas spp.
Proteus.
5. Bacteroides: Bacteroid Fragilis
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Causative agents in SSI based
on % isolates

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Risk factors

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Cont’d…

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Cont’d…

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Pathophysiology

• Activation of inflammation occurs by cuts, incisions, abrasions,

burns. This initiates inflammation by protein coagulation, platelet
aggregation, mast cell activity, release of complements and
bradykinin.
• Phase I of inflammation begins with vasodilatation, increased bulk
flow, increased vascularity. Later Phase II of inflammation proceeds
with phagocytic infiltration and bacterial phagocytosis, removal of
dead tissue with release of pro- inflammatory cytokines.

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Cont’d…
• Here tissue injury from incision mobilizes phagocytes before bacterial
contamination leading into prior preparation against infection. If contamination is
controlled monocytes activate to regulate wound healing using myofibrocytes
and collagen.
• If bacterial contamination is not controlled, pro- inflammatory cells release
TNF-α to stimulate neutrophils for phagocytosis.

• It also causes release of reactive oxygen and acid hydrolases from lysosomal
vacuoles to result in lipid peroxidation, release of interleukins, evoking acute
inflammatory response with creation of space containing pus which contains
necrotic tissue, neutrophils, bacteria and proteinaceous fluid with all signs of
inflammation—rubor, dolor, calor, tumour. It is typical surgical site infection (SSI).

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Defense Barriers
 Physical: normal epithelial barrier
 Chemical: low gastric pH;
 Immunologic:
 Humeral: antibodies, complement and opsonins;
 Cellular: phagocytic cells, macrophages, polymorphonuclear cells
and killer lymphocytes.

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Causes of reduced host
resistance to infection
 Metabolic: malnutrition (including obesity), diabetes, uraemia,
jaundice.
■ Disseminated disease: cancer and acquired immunodeficiency
syndrome (AIDS).
■ Iatrogenic: radiotherapy, chemotherapy, steroids.

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Classification of SSI
• Physical Status classification
• Class I: A patient in normal health.
• Class II: A patient with mild systemic disease resulting in no functional
limitations.
• Class III: A patient with severe systemic disease that limits activity, but
is not incapacitating.
• Class IV: A patient with severe systemic disease that is a constant
threat to life.
• Class V: A moribund patient not likely to survive 24 hours.

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Cont’d…
Classification of Wound Infection According to the Aetiology
a. Primary infection where the wound is the primary site of infection.
b. Secondary infection arises following a complication that is not
directly related to the wound.
Classification of Wound Infections According to the Time
a. An early infection presents within 30 days of a surgical procedure.
b. An intermediate infection occurs between 1-3 months afterwards.
c. Late infection occurs in more than three months after surgery.

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 Cont’d…
 Classification of Wound Infections According
to the Severity
a. Minor wound infection if there is discharge
without cellulitis or deep tissue destruction.
b. Major if the discharge of pus is associated
with tissue breakdown, partial or total
dehiscence of the deep fascial layers of the
wound, or if systemic illness is present.
• Note: Please refer first page of this Chapter for
Southampton wound grading system and
Asepsis wound score system
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Southampton Wound Grading
system

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Asepsis wound Scoring system

SCORE OF 0 TO 10: satisfactory healing.

SCORE OF 11 TO 20 : unsatisfactory healing.
SCORE OF 21 TO 30: Minor wound infection.
SCORE OF 31 TO 40: moderate wound
infection.
SCORE OF >41: severe wound infection.

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 Centers for Disease Control and Prevention
Classification of Surgical Site Infection

Superficial Incisional
Infection less than 30 days after surgery
Involves skin and subcutaneous tissue only, plus one of the following:
▪ Purulent drainage
▪ Diagnosis of superficial site infection by a surgeon
▪ Symptoms of erythema, pain, local edema

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 Centers for Disease Control and Prevention
Classification of Surgical Site Infection
Organ Space Deep Incisional
Infection less than 30 days after surgery with no implant Less than 30 days after surgery with no implant and soft tissue involvement
Infection less than 1 year after surgery with an implant; involves deep soft
Infection less than 1 year after surgery with an implant and infection; involves tissues (fascia and muscle), plus one of the following:
any part of the operation opened or manipulated, plus one of the following:
▪ Purulent drainage from the deep space but no extension into the organ
▪ Purulent drainage from a drain placed in the organ space space
▪ Cultured organisms from material aspirated from the organ space ▪ Abscess found in the deep space on direct or radiologic examination or
on reoperation
▪ Abscess found on direct or radiologic examination or during
▪ Diagnosis of a deep space site infection by the surgeon
reoperation
▪ Symptoms of fever, pain, and tenderness leading to dehiscence of the
▪ Diagnosis of organ space infection by a surgeon wound or opening by a surgeon

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SSI classification based on degree of contamination

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 When to Suspect SSIs?
• A postoperative patient has elevated temperature, tachycardia, tachypnoea with elevated white
blood cell count (WBC).

• The wound shows signs of inflammation such as rubor, colour, dolor and tumour (swelling). These
are the part of SIRS (systemic inflammatory response yndrome).

• Wound is tender with discharge

• Microorganisms are identified in the blood, pus or in the urine.

• SIRS can be caused by variety of diseases such as pancreatitis, polytrauma, malignancies,

transfusion reactions as well as infection.

• SIRS caused by infections is termed sepsis.

• SIRS is mediated by production of proinflammatory mediators such as lipopolysaccharides
(endotoxin) derived from gram-negative organisms and peptidoglycans from gram-positive
bacteria.
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Defense Barriers
 Physical: normal epithelial barrier
 Chemical: low gastric pH;
 Immunologic:
 Humeral: antibodies, complement and opsonins;
 Cellular: phagocytic cells, macrophages, polymorphonuclear cells
and killer lymphocytes.

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Causes of reduced host
resistance to infection
Metabolic: malnutrition (including obesity), diabetes, uraemia,
jaundice.
■ Disseminated disease: cancer and acquired immunodeficiency
syndrome (AIDS).
■ Iatrogenic: radiotherapy, chemotherapy, steroids.

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Factors that determine whether
a wound will become infected
■ Host response
■ Virulence and inoculum of infective agent
■ Vascularity and health of tissue being invaded (including local
ischaemia as well as systemic shock)
■ Presence of dead or foreign tissue
■ Presence of antibiotics during the ‘decisive period’

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Clinical Criteria
• A purulent exudate draining from the surgical site.
• A positive fluid culture obtained from a surgical site that was closed
primarily.
• A surgical site that requires reopening.
• The wound drains fluid that is culture positive or Gram stain positive
for bacteria.
• The surgeon notes erythema or drainage and opens the wound after
deeming it to be infected.

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Variables that Influence SSI

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The National Nosocomial Infections
Surveillance (NNIS) System as Basic SSI Risk
Index
Note:
 T point for common surgical procedures
are—coronary artery bypass graft—5;

 Bile duct, liver or pancreatic surgery,

craniotomy, head and neck surgery—4;

 Colonic surgery, joint prosthesis

surgery, vascular surgery—3;

 Abdominal or vaginal hysterectomy,

ventricular shunt, herniorrhaphy—2;

 Appendicectomy, limb amputation,

caesarean section—1.

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Prevention of SSI

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Preoperative phase (hair
removal)
• Do not routinely use hair removal

• Do not use razors for hair removal, as they increase

the risk of surgical site infection

• If hair has to be removed, use electric clippers with

a single-use head on the day of surgery

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Preoperative phase (antibiotic prophylaxis)

•Give antibiotic prophylaxis before:

- clean surgery for the placement of a prosthesis or implant
- clean-contaminated surgery
- contaminated surgery

•Do not routinely use for clean non-prosthetic uncomplicated

surgery

•Use local antibiotic formulary and consider adverse effects

•Consider prophylaxis on starting anaesthesia, or

earlier for operations using a tourniquet.

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Antimicrobial agents
• Penicillins, Cephalosporins, carbapenems - inhibit
cell wall synthesis, resulting in bacteriolysis.
• Tetracyclins, chloramphenicol, and macrolides -
inhibit bacterial ribosomal activities and thus overall
protein synthesis.
• Vancomycin - inhibits assembly of peptido glycan
polymers.
• Quinolones - inhibit bacterial DNA synthesis.
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Prophylactic Antibiotics
• General agreement exists that prophylactic antibiotics are indicated
for clean-contaminated and contaminated wounds.

• Antibiotics for dirty wounds are part of the treatment because

infection is established already.

• Clean procedures might be an issue of debate. No doubt exists

regarding the use of prophylactic antibiotics in clean procedures in
which prosthetic devices are inserted because infection in these cases
would be disastrous for the patient.
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Choice of antibiotics for
prophylaxis
- Empirical cover against expected pathogens with local hospital
guidelines
■ Single-shot intravenous administration at induction of anaesthesia
■ Repeat only in prosthetic surgery, long operations or if there is
excessive blood loss
■ Continue as therapy if there is unexpected contamination
■ Benzylpenicillin should be used if Clostridium gas gangrene infection is
a possibility
■ Patients with heart valve disease or a prosthesis should be protected
from bacteraemia caused by dental work, urethral instrumentation or
visceral surgery
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Systemic preventive antibiotics should
be used in the following cases
• A high risk of infection is associated with the procedure (eg, colon resection).
• Consequences of infection are unusually severe (eg, total joint replacement).
• Postoperative administration of preventive systemic antibiotics beyond 24 hours
has not been demonstrated to reduce the risk of SSIs.

Intraoperative Re – dosing performed :-

• Operation is prolong
• If massive blood loss occurs
• The patient is obese

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Prophylaxis guideline for specific
procedures

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Cont’d…

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Prevention Cont’d…
• Despite evidence of effectiveness of preoperative antimicrobials for SSI
prevention and the publication of guidelines for antimicrobial prophylaxis, it
was recognized that use was often suboptimal.

• As part of the SIP initiative, three SIP performance measures were developed:

• SIP-1: Antibiotic timing: Proportion of patients in whom IV antimicrobial

prophylaxis is initiated within 1 hour before incision.
• SIP-2: Antibiotic selection: Proportion of patients are given prophylactic
antimicrobials consistent with published guidelines.
• SIP-3: Antibiotic discontinuation within 24 hours: Proportion of patients
whose antimicrobial prophylaxis is discontinued within 24 hours after surgery.
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Prevention of SSI summary

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Prevention of SSI summary

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Complications

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Management of SSI

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