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RESEARCH ARTICLE Nakka nasara Reddy et.al / IJIPSR / 2 (6), 2014, 1107-1120

Department of Pharmacy Practice ISSN (online) 2347-2154

Available online: www.ijipsr.com June Issue 1107

STUDY ON SURGICAL WOUND INFECTIONS AND PATTERN

OF ANTIBIOTICS USE IN A SURGICAL UNIT OF TERTIARY

CARE TEACHING HOSPITAL

1Nakka Nasara Reddy*,

2A. Avinash,

3K. Phani sree Harsha,

4Sappa Dilip Kumar,

5R.T.saravana Kumar,

6N. Junior Sundresh

1,2,3,4

Pharm-D 5th

year, Annamalai University, Chidambaram, INDIA 5Assistant professor, Department of pharmacy, Annamalai university, Chidambaram, INDIA 6Reader in surgery, Rajah Muthiah medical college, Annamalai university, Chidambaram,

INDIA

Corresponding Author:

Nakka nasara Reddy

Pharm-D 5th

year,

Annamalai University, Chidambaram, INDIA

E-mail: [email protected]

Ph.No: 08297079706

International Journal of Innovative

Pharmaceutical Sciences and Research www.ijipsr.com

Abstract

The purpose of the study was to observe the frequency of surgical wound infections and the pattern of

antibiotics use at different surgical units in the Department of surgery at Rajah Muthiah Medical College &

Hospital (RMMCH).A 1400 bedded multi-specialty tertiary care teaching hospital. A total of 338 post

operative patients were included in this study over 6 months period. The incidence rate of surgical site

infections found in the present study was 23 (6.8%) out of 338 patients. Out of 23 Wound Infected patients

12(52.17%) had dirty wounds, contaminated wounds 8(34.78%). Among the 23 wound infected patients 32

organisms were isolated. The pathogens isolated from SWI were staphylococcus aureus 34.4%, Pseudomonas

21.9%.The staphylococcus aureus was more susceptible to amikacin 90.9%, Proteus mirabilus was more

susceptible to ofloxacin 100%, Klebsiella was more susceptible to amikacin 83.3%, Pseudomonas was more

susceptible to ceftriazone 85.7% and E.coli was more susceptible to amikacin 83.3%. In the present study

diabetes, smoking, anemia and obesity are the major underlying risk factors. Hence successful management

of risk factors leads to better control of SSI’s. Lack of adequate surveillance programs in rural regions and

statistical data on nosocomial infections are found to be the problems needed to be addressed.

Keywords: Frequency of surgical wound infection, Type of wound, Risk factors, Antibiotics.

mailto:[email protected]




INTRODUCTION

Surgical site infection (SSI) may be defined as “invasion and multiplication of microorganisms

in body tissue which may be clinically in apparent / result in local cellular injury because of

competitive metabolism, toxins, intracellular replication or artigen- anti body response”[1].

Surgical Site Infection (SSI) is the most common post-operative complication and represents a

significant burden in terms of patient morbidity, mortality and cost to health services around the

world [2]. Based on the National Nosocomial Infections Surveillance, SSIs are the third most

frequently reported nosocomial infections, accounting for 14-16% of all the nosocomial

infections [3]. Excessive and inappropriate use of antibiotics in health care facilities and the

communities contributes to development of antibiotic resistance. Multiple antibiotics are

available and information about antibiotic use pattern is necessary to formulate a constructive

approach to the problem of inappropriate drug use [4]. Appropriate surgical antibiotic

prophylaxis (SAP) can reduce the postoperative wound infection. Inappropriate use increases the

selective pressure and favours the development of antimicrobial resistance [5]. Surgical site

infections (SSI) are a real problem to the surgeons and are considered as major infection control

concern across the world [6-8]. In the United States, every year SSI develops in 2%-5% of

patients, resulting in at least 500,000 infections, 3.7 million excess hospital days and $1.6 billion

in extra hospital charges [8].

AIM OF THE STUDY

The purpose of the study was to observe the frequency of surgical wound infections and the

pattern of antibiotics use at different surgical units in the Department of surgery at Rajah

Muthiah Medical College & Hospital, Annamalai Nagar-608 002, Tamilnadu, India, a 1400

bedded multi-specialty tertiary care teaching hospital.

MATERIALS & METHODS

This was a Prospective Observational Study carried out over a 6 month period from November

2013- April 2014. A total of 338 post surgical patients were included in this study and the

patients were selected based on the inclusion & exclusion criteria.




Inclusion Criteria:

Patients admitted in surgery wards for various surgeries between the age group of 14 -

80 years.

Patients who are newly diagnosed and already underwent various surgical procedures.

Exclusion Criteria:

Patients above 80 years of age.

Patients who are not willing to participate

DESIGNING DATA COLLECTION FORM:

The first step in the study is to design a Data collection form. A patient data collection form was

used to collect all the details like Inpatients number, Patient name, Age, Sex, height, weight,

Date of admission, Date of surgery, Date of discharge, Chief complaints (C/O), History of

Present Illness (HOPI), Past Medication history, Laboratory data, Culture sensitivity test, clinical

Diagnosis, surgery procedure executed, and prophylactic antibiotics prescribed.

Type of surgery procedure:

a) Clean

b) Clean Contaminated

c) Contaminated

d) Dirty

Post operative wound infection:

Superficial SSI: ( )

Organ/space SSI: ( )

Deep SSI: ( )

The culture test was done by Differential and Selective media. The identification of type of

bacteria was done by gram staining method [9 ]. According to the CDC and NINS [10, 11]. The

surgical wound infections (SWI) were categorized into the following ways based on the site of

the infection (fig.1).




(i) Superficial incisional SWI:

Occurs within 30 days after the operation involving only the skin or subcutaneous tissue.

Purulent drainage is present. Organisms are isolated from fluid/tissue of the superficial incision.

At least one sign of inflammation example: pain or tenderness, indurations, erythema, local

warmth of the wound will be present.

(ii) Deep incision SWI:

Occurs within 30 days of the operation or within 1 year if an implant is present. It involves deep

soft tissues (muscle) of the incision. Purulent drainage is present from the deep incision but

without organ space involvement.

(iii) Organ Space SWI:

It also occurs within 30days of the operation or within 1 year if an implant is present. It may also

involve anatomical structures not opened or manipulated during the operation. Purulent drainage

is present from a drain placed by a stab wound into the organ space.

According to the CDC and NINS [10,11,12]. The wound infections class was classified in the

following ways:

(I)Clean Wounds:

These constitute




(IV) Dirty or Infected Wounds:

This class constitutes highest percentage of infections that is 40% of infection risk. These include

old traumatic wounds with retained devitalized tissue and those that involve existing clinical

infection or perforated viscera.

Fig 1: surgical wound infections based on the surgical site

RESULTS & DISCUSSION

1. AGE WISE DISTRIBUTION: A total of 338patients belonging to various age groups were

included in study, out of which 23 patients were identified with SWI. Rate of surgical wound

infection was found to be more in people belonging to age group 51-60 (10.1%), followed by

41-50 (9.2%),14-20 (4.3%).

Fig 2: Age wise Distribution

2329

48

76

89

48

25

1 1 27 9

2 10

20

40

60

80

100

14-2021-3031-4041-5051-6061-7071-80

Total no. of patients




Table 1: Sex wise Distribution

Gender Total no of patients % No of patients with SWI %

Male 203 60.0 15 65.22

Female 135 40.0 08 34.78

Total 338 100 23 100

Out of 338 patients 203(60%) were males and 135(40%) were females. The rate of incidence of

SWI was found to be more in males 15 (65.22%) than the females 8 (34.78%).

Table 2: Surgery Procedure

The SWI was found to be more in emergency procedure 15(65.22%) compared with elective

procedures 8 (32.84%).

Table 3: Percentage of patients with SWI with respect to operative procedure

Operative procedure No. of patients %

Incision & drainage 4 17.39

Appendicectomy 2 8.69

Hernioplasty 1 4.34

Laprotomy 2 8.69

Cancer theraphy surgeries 2 8.69

Split skin graft 3 13.0

Fasciotomy 1 4.34

Wound debridement 5 21.73

Amputation 2 8.69

Others 1 4.34

Total 23 100

The Wound Infection was found to be more in Wound debridement (21.73%) followed by

Incision & drainage (17.39%), Amputation, Appendicectomy, Laparotomy & Cancer theraphy

surgeries were 8.69% respectively.

Elective Emergency

Total % of SWI Total % of SWI

227 (67.16) 8(34.78) 111 (32.84) 15(65.22)




Fig. 3: Percentage of patients with SWI with respect to operative procedure

Table 4: Percentage of SWI with respect to wound class

Wound classification No. of procedures Percentage

Clean 1 4.34

Clean Contaminated 2 8.69

Contaminated 8 34.78

Dirty/ infected 12 52.17

23 Wound Infected patients 12(52.17%) had dirty wounds, followed by contaminated wounds

8(34.78%), Clean Contaminated 2 (8.69%) & Clean wounds 1(4.34%).

Fig. 4: Percentage of SWI with respect to wound class

17.39%

8.69%

4.34%

8.69%

8.69%13%

4.34%

21.73%

8.69%

4.34%Incision & drainage

Appendicectomy

Hernioplasty

Laparotomy

Cancer theraphy surgeries

Split skin graft

Fasciotomy

Wound debridement

Amputation

4.348.69

34.78

52.17

0

10

20

30

40

50

60

Per…




Table 5: Surgical wound infection with respect to surgical site

Surgical site No. of patients with SWI % of patients with SWI

Superficial 17 74

Organ space 4 17.3

Deep 2 8.7

Fig. 5: Surgical wound infection with respect to surgical site

Table 6: RISK FACTORS

Table 6(i): (Obesity)

Body Mass Index SSI %

BMI




a) Weight & Height

Body Mass index greater than 40 was identified as a risk factor for postoperative wound

infection. Followed by 26% with body mass index of ≥35 and




Table 8: Clinical and Bacteriological Study

Type No. of organisms %

Gram positive 13 40.62

Gram negative 19 59.38

Total 32 100

Out of 23 cases 32 organisms were isolated of these 13 (40.62%) were gram positive bacteria

and 19(59.38%) were gram negative bacteria.

Antibiotic Sensitivity Pattern of Staphylococcus Aureus (11 Isolates)

11 isolates of Staphylococcus aureus from pus was observed, 63.6% were susceptible to

imipenem and pefloxacin, 36.4% were susceptible to Erythromycin and Gentamycin, 27.3%

were susceptible to Oxacillin, 54.5% were susceptible to Ampicillin and Ciprofloxacin, 90.9%

were susceptible to Amikacin, 81.9% were susceptible to Ofloxacin and Vancomycin ,44.4%

were susceptible to Ceftriazone : 36.4% were resistant to imipenem and pefloxacin, 63.6% were

resistant to Erythromycin and Gentamycin, 72.7% were resistant to Oxacillin, 45.5% were

resistant to Ampicillin and Ciprofloxacin, 9.1% were resistant to Amikacin, 18.1% were

resistant to Ofloxacin and Vancomycin ,55.6% were resistant to Ceftriazone.




Antibiotic Sensitivity Pattern of Proteus Mirabilus: (2 Isolates)

2 isolates of Proteus mirabilus from pus sample was observed.100% were susceptible to

pefloxacin and ofloxacin, 50% were susceptible to imipenem, amikacin, gentamycin and

ceftriazone.100% were resistant to ampicillin, 50% were resistant to imipenem, amikacin,

gentamycin and ceftriazone.

Antibiotic Sensitivity Pattern of Klebsiella: (6 Isolates)

6 isolates of klebsiella from pus sample was observed. 83.7% were susceptible to pefloxacin and

amikacin, 66.6% were susceptible to imipenem, 50% were susceptible to ofloxacin and

ceftriazone. 100% were resistant to ampicillin and gentamycin, 50% were resistant to ofloxacin

and ceftriazone, 33.4% were resistant to imipenem, 16.7% were resistant to pfloxacin and

amikacin.




Antibiotic Sensitivity Pattern Of Pseudomonas: (7 Isolates)

7 isolates of Pseudomonas from pus sample was observed. 85.7% were susceptible to

ceftriazone, 71.4% were susceptible to gentamycin and Iofloxacin, 57.2% were susceptible to

ciprofloxacin and amikacin, 42.8% were susceptible to imipenem. 100% resistant to ampicillin,

57.2% were susceptible to imipenem, 42.8% were resistant to ciprofloxacin and amikacin, 28.6%

were resistant to ofloxacin and gentamycin, 14.3 resistant to ceftriazone.

DISCUSSION

In this present study the rate of surgical wound infection (SWI) was 6.8% less when compare to

surgical site infection and Antibiotics use pattern in a tertiary care hospital in Nepal [13]. And

the incidence rate was higher when compared to USA [14]. The surgical incidence was 52.17%

in dirty wounds, followed by 34.78% in contaminated wounds, 8.69% in Clean Contaminated &

4.34% in Clean wounds. Rate of surgical wound infection was found to be more in people




belonging to age group 51-60 (10.1%).The rate of incidence of SWI was found to be more in

males 15 (65.22%) than the females 8 (34.78%).The SWI was found to be more in emergency

procedure 15(65.22%) compared with elective procedures 8 (32.84%). The Wound Infection was

found to be more in Wound debridement (21.73%).superficial incision site infection was

observed in 17 (74%) followed by organ space 4 (17.3%) and deep incision site 2(8.7%).The risk

factors observed in this present study were obesity, diabetes, smoking and anaemia levels.

Among the 23 wound infected patients 32 organisms were isolated. The pathogens isolated from

SWI were staphylococcus aureus 34.4% , Pseudomonas 21.9%, Klebsiella 18.7%, E.coli 18.7&

and the Proteus mirabilus 6.3%. The antibiotic sensitivity pattern was done for the isolated

organisms. The staphylococcus aureus was more susceptible to amikacin 90.9%, Proteus

mirabilus was more susceptible to ofloxacin 100%, Klebsiella was more susceptible to amikacin

83.3%, Pseudomonas was more susceptible to ceftriazone 85.7% and E.coli was more

susceptible to amikacin 83.3%.

CONCLUSION

The incidence rate of surgical site infections found in the present study was 23 (6.8%) out of 338

patients. The most commonly isolated organisms in SWI were Staphylococcus aureus (34.4%),

Pseudomonas (21.9%), Klebsiella (18.7%), E.coli (18.7%) and Proteus mirabilus (6.3%). In the

present study diabetes, smoking, anaemia and obesity are the major underlying risk factors.

Hence successful management of risk factors leads to better control of SSI’s. Lack of adequate

surveillance programs in rural regions and statistical data on nosocomial infections are found to

be the problems needed to be addressed. Amikacin and ofloxacin were more susceptible to

organisms isolated in SWI followed by Gentamycin. Cefotaxime was the most commonly

preferred antibiotic prophylaxis in this study.

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