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2010 : 16 million operative procedures wereperformed (US).
Recent prevalence study : SSIs were the mostcommon healthcare-associated infection,31% of all HAIs among hospitalized patients.
NHSN data : 2006-2008 (16,147 SSIs -849,659 procedures) showed an overall SSIrate of 1.9%.
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Advances have been made in infectioncontrol practices; improved operating roomventilation, sterilization methods, barriers,
surgical technique, and availability ofantimicrobial prophylaxis
SSIs remain a substantial cause of morbidityand an associated mortality rate of 3% hasbeen attributed to them.
Of this, 75% of the mortality rate has beendirectly related to the SSI.
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Surveillance of SSI w/ feedback ofappropriate data to surgeons - shown to bean important component of strategies to
reduce SSI risk. A successful surveillance program includes
the use of epidemiologically-sound infectiondefinitions and effective surveillancemethods, stratification of SSI rates accordingto risk factors associated with SSIdevelopment, and data feedback.
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Definition
The Centers for Disease Control and Prevention(CDC) term for infections associated with surgical
procedures was changed from surgical woundinfection to surgical site infection in 1992
These infections are classified into incisional, organ,or other organs and spaces manipulated during anoperation; incisional infections are further divided
into superficial (skin and subcutaneous tissue) anddeep (deep soft tissue-muscle and fascia)
These definitions should be followed universally forsurveillance, prevention, and control of surgical site
infections.
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Operative Procedure
Procedure that is performed on a patient whois an inpatient or an outpatient; and
takes place during an operation (defined as asingle trip to the operating room [OR] wherea surgeon makes at least one incision throughthe skin or mucous membrane, including
laparoscopic approach, and closes theincision primarily* before the patient leavesthe OR)
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ASA Score
Assessment by the anesthesiologist of thepatients preoperative physical condition usingthe American Society of Anesthesiologists (ASA)Classification of Physical Status
1. Normally healthy patient2. Patient with mild systemic disease
3. Patient with severe systemic disease that is notincapacitating
4. Patient with an incapacitating systemic diseasethat is a constant threat to life
5. Moribund patient (< 24hr)
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Surgical Wound Classif ication
Class Iclean. Uninfected operative wound withno inflammation and in which the respiratory,gastrointestinal (GI), genital and urinary tracts were
not entered. Clean wounds are closed at surgery and,if necessary, drained with closed drainage.
Class IIclean-contaminated. Wound in which therespiratory, GI, genital or urinary tract(s) were
entered under controlled conditions but withoutunusual contamination or spillage of contents.
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Surgical Wound Classif ication
Class IIIcontaminated. Open, fresh accidentalwound or an operation with a major break(s) inaseptic technique (e.g., open cardiac massage) or
gross spillage from the GI tract. Also included areincisions in which acute, nonpurulent inflammationis found.
Class IVdirty or infected. Old wounds with dead
tissue and those that involve existing clinicalinfection or a perforated bowel, suggesting that the
pathogens causing the postoperative infection werepresent in the wound before the surgery.
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Superf icial I ncisional SSI
must meet one of the following criteria:
Infection occurs within 30 days after the operativeprocedure and involves only skin and subcutaneous
tissue of the incision and patient has at least one ofthe following:
purulent drainage from the superficial incision.
organisms isolated from an aseptically obtainedculture of fluid or tissue from the superficialincision.
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Superficial Incisional SSI
at least one of the following signs or symptoms of
infection: pain or tenderness, localized swelling,
redness, or heat, and superficial incision isdeliberately opened by surgeon, and is culture-positive or not cultured. A culture-negative finding
does not meet this criterion.
diagnosis of superficial incisional SSI by the
surgeon or attending physician
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Deep Incisional SSI
must meet one of the following criteria:
Infection occurs within 30 days after the operative procedureif no implant is left in place or within one year if implant is
in place and the infection appears to be related to the operative
procedure and involves deep soft tissues (e.g., fascial andmuscle layers) of the incision
and patient has at least one of the following:
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Deep Incisional SSI
purulent drainage from the deep incision but not from theorgan/space component of the surgical site
a deep incision spontaneously dehisces or is deliberatelyopened by a surgeon and is culture- positive or not cultured
and the patient has at least one of the following signs orsymptoms: fever (>38C), or localized pain or tenderness. Aculture-negative finding does not meet this criterion.
an abscess or other evidence of infection involving the deep
incision is found on direct examination, during reoperation,or by histopathologic or radiologic examination
diagnosis of a deep incisional SSI by a surgeon or attendingphysician
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Organ / Space SSI
An organ/space SSI must meet one of the followingcriteria:
Infection occurs within 30 days after the operative
procedure if no implant is left in place or within oneyear if implant is in place and the infection appearsto be related to the operative procedure
And infection involves any part of the body,excluding the skin incision, fascia, or muscle layers,that is opened or manipulated during the operative
procedure
and
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Organ / Space SSI
patient has at least one of the following:
purulent drainage from a drain that is placed througha stab wound into the organ/space
organisms isolated from an aseptically obtainedculture of fluid or tissue in the organ/space
an abscess or other evidence of infection involvingthe organ/space that is found on direct examination,during reoperation, or by histopathologic orradiologic examination
diagnosis of an organ/space SSI by a surgeon or
attending physician.
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Prevention
Preparation of the Patient
Ventilation
Hand/forearm antisepsis for surgical team members
Management of infected or colonized surgicalpersonnel
Antimicrobial Prophylaxis
Surgical Attire and Drapes
Preoperative Hand & Forearm Antisepsis
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Preparation of the Patient
Identify and treat all infections remote to thesurgical site before elective operation andpostpone elective operations on patients with
remote site infections until the infection hasresolved. Category IA
Do not remove hair preoperatively unless the
hair at or around the incision site will interferewith the operation. Category IA
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Preparation of the Patient
If hair is removed, remove immediatelybefore the operation, preferably with electricclippers. Category IA
Adequately control serum blood glucoselevels in all diabetic patients and particularlyavoid hyperglycemia perioperatively.
Category IB
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Preparation of the Patient
Stopping use of tobacco products. At minimum,instruct patients to abstain for at least 30 daysbefore elective operation from smoking
cigarettes, cigars, pipes or any other form oftobacco consumption (e.g., chewing/ dipping).Category IB
Do not withhold necessary blood productsfrom surgical patients as a means to prevent SSI.Category IB
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Preparation of the Patient
Require patients to shower or bathe with anantiseptic agenton at least the night before theoperative day. Category IB
Thoroughly wash and clean at and around theincision site to remove gross contaminationbefore performing antiseptic skin preparation.
Category IB
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Preparation of the Patient
Use an appropriate antiseptic agent for skinpreparation (Table 6). Category IB
Keep preoperative hospital stay as short aspossible while allowing for adequatepreoperative preparation of the patient.Category II
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Ventilation
Maintain positive-pressure ventilation in theoperating room with respect to the corridorsand adjacent areas. Category IB
Maintain a minimum of 20 air changes perhour, of which at least 4 should be fresh air.Category IB
Filter all air, recirculated and fresh, throughthe appropriate filters per the AmericanInstitute of Architects recommendations.Category IB
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Ventilation
Introduce all air at the ceiling, and exhaustnear the floor. Category IB
Do notuse UVradiation in the operatingroom to prevent SSI. Category IB
Keep operating room doors closed except asneeded for passage of equipment, personnel
and the patient. Category IB
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Ventilation
Consider performing orthopedic implantoperations in operating rooms supplied withultraclean air. Category II
Limit the number of personnel entering theoperating room to necessary personnel.Category II
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Hand/forearm antisepsis for
surgical team members
Keep nails short and do not wear artificial nails.Category IB
Perform a preoperative surgical scrub for at least2 to 5 minutes using an appropriate antiseptic.Scrub the hands and forearms up to the elbows.Category IB
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Hand/forearm antisepsis for
surgical team members
After performing the surgical scrub, keephands up and away from the body (elbows inflexed position) so that water runs from thetips of the fingers toward the elbows. Dryhands with a sterile towel and put on a sterilegown and gloves. Category IB
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Management of infected or
colonized surgical personnel
Educate and encourage surgical personnel whohave signs and symptoms of a transmissible
infectious illness to report conditions promptly totheir supervisory and occupational health servicepersonnel.Category IB
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Management of infected or
colonized surgical personnel
Develop well-defined policies concerning patientcare responsibilities when personnel havepotentially transmissible infectious conditions.These policies should govern: (a) personnelresponsibility in using the health service andreporting illness, (b) work restrictions, and (c)
clearance to resume work after an illness thatrequired work restriction. The policies also shouldidentify persons who have the authority toremove personnel from duty.Category IB
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Management of infected or
colonized surgical personnel
Exclude from duty surgical personnel who havedraining skin lesions until infection has beenruled out or personnel have received adequate
therapy and infection has resolved. CategoryIBDo not routinely exclude surgical personnel whoare colonized with organisms such as S. aureus
(nose, hands or other body site) or group AStreptococcus, unless such personnel have beenlinked epidemiologically to dissemination of theorganism in the healthcare setting. Category IB
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Antimicrobial Prophylaxis
Administer a prophylactic antimicrobial agentonly when indicated, and selectit based on itsefficacy against the most common pathogenscausing SSI for a specific operation and published
recommendations. Category IA
Do notroutinely use vancomycin forantimicrobial prophylaxis. Category IB
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Antimicrobial Prophylaxis
Administer by the intravenous route theinitial doseof prophylactic antimicrobialagent, timedsuch that a bactericidal
concentration of the drug is established inserum and tissues when the incision is made.Maintain therapeutic levels of the agent inserum and tissues throughout the operation
and until, at most, a few hours after theincision is closed in the operating room.Category IA
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Antimicrobial Prophylaxis
Before elective colorectal operations in additionto above, mechanically prepare the colon by useof enemas and cathartic agents. Administer
nonabsorbable oral antimicrobial agents individed doses on the day before the operation.Category IA
For high-risk cesarean section, administer the
prophylactic antimicrobial agent immediatelyafter the umbilical cord is clamped. Category IA
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Surgical Attire and Drapes
Wear a surgical mask that fully covers the mouthand nose when entering the operating room if anoperation is about to begin or already under way
or if sterile instruments are exposed. Wear themask throughout the operation.Category IB
Wear a cap or hoodto fully cover hair on thehead and face when entering the operating
room.Category IB
Do not wear shoe covers for the prevention ofSSI.Category IB
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Surgical Attire and Drapes
Wear sterile gloves if a scrubbed surgical teammember. Put on gloves after putting on a sterilegown.Category IB
Use surgical gowns and drapes that areeffective barriers when wet(i.e., materials thatresist liquid penetration).Category IB
Change scrub suits that are visibly soiled,contaminated and/or penetrated by blood orother potentially infectious materials.Category IB
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Asepsis and Surgical Technique
Adhere to principles of asepsis when placingintravascular devices, spinal or epiduralanesthesia catheters, or when dispensing and
administering intravenous drugs.Category IAHandle tissue gently, maintain effectivehemostasis, minimize devitalized tissue andforeign bodies (i.e., sutures, charred tissues,
necrotic debris) and eradicate dead space at thesurgical site.Category IB
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Asepsis and Surgical Technique
Use delayed primary skin closure or leave anincision open to heal by second intention if thesurgeon considers the surgical site to be heavily
contaminated (e.g., Class III and Class IV).Category IB
If drainage is necessary, use a closed suctiondrain. Place a drain through a separate incision
distant from the operative incision. Remove thedrain as soon as possible. Category IB
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Postoperative Care
Protect with a sterile dressingfor 24 to 48 hourspostoperatively an incision that has been closedprimarily. Category IB
Wash hands before and after dressing changesand any contact with the surgical site. CategoryIB
When an incision dressing must be changed, usesterile technique. Category II
Educate the patient and family regarding properincision care, symptoms of SSI, and the need to
report such symptoms. Category II
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Data Analyses
Basic SSI Risk Index. The index used in NHSNassigns surgical patients into categories based on the
presence of three major risk factors:
1. Operation lasting more than the duration cut point
hours, where the duration cut point is theapproximate 75th percentile of the duration of
surgery in minutes for the operative procedure (1)
2. Contaminated (Class 3) or Dirty/infected (Class 4)
wound class (1)
3. ASA classification of 3, 4, or 5 (1)
sum of the number of these factors present at
the time of the operation
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Data Analyses
The SSI rates per 100 operative procedures are
calculated by dividing the number of SSIs by the
number of specific operative procedures and
multiplying the results by 100
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