SURGICAL SITE INFECTIONIN SURGERY

Dr. Soetomo Hospital’s Experience

Paul L.Tahalele MD, PhD

Consultant of thoracic – Cardiovascular Surgery

Chief of Cardiac Surgical Team

Surabaya Heart & Vascular Center

Airlangga University Medical Center Dr. Soetomo Teaching Hospital

Surabaya - Indonesia

SSI, what is the problem faced by

Indonesian Healthcare System

1. Indonesia is a big country consist thousands

Islands (220 million people) has big healthcare

problem with limited heatlh care resources.

Indonesian has approximately 110 type A & B

State Hospital.

2. The Indonesian Healthcare system is aware of

the dangers of Healthcare Associated Infection

(HAI).

3. So far, there are no published data on infection

control in Indonesia (focus on SSI).

(Offra Duerink. J. of Hosp. Infection 2006 Feb; 62(2):219-29)

SSI, what is the problem faced by

Indonesian Healthcare System

Based on above, the Director of Dr. Soetomo Hospital

establish AMRIN program (Antimicrobial Resistance in

Indonesia), it is joint collaboration with Prof. Dr. Henri A.

Verbrugh, a Microbiologist from Erasmus University

Medical Center Amsterdam. The result of AMRIN study

2001:

a. The quality assessment of Ab. Usage in Department of Surgery

in Surabaya shows that there is no indication between 30-68%

and inappropriate Ab. use between 19-21%

b. Dr. Offra Duerink et al reported the result of surveillance of

health care associated infection in Indonesian Hospital (2001-

2002), with focus on SSI: The Prevalance of SSI was 5.3% both

after clean and clean contaminated and 12% after dirty operation

(J of Hosp Infection 2006 Feb; 62(2): 219-29). This study was

performed in two Indonesian University Hospitals (Surabaya &

Semarang)

The next step: establish a program together with all

surgical staff members and commit to overcome that

problems.

In 2003:

1. After evaluation of the result of AMRIN Study

2001, we renewed & updating the antibiotic

guideline 1992 (1st Ab guideline in Dr. Soetomo

Hospital).

2. Socialization to the staff performed around 3

months

3. Training activities to the 60 residents of surgery

4. Begin action with the new antibiotic guideline at

the Depart. of Surgery Dr. Soetomo General

Hospital

SSI or Infection in Surgery

contributed by many risk

factors

2. Risk of

infection

MW Mulholland & GM Doherty (2006).

Complications in Surgery, Lippincott Williams

& Wilkins, Philadelpia, pp 114-125

1.Skin

preparation

2.Operating

room

3.Operative

technique

4.Tissue

oxygenation

water, Sterile ??

Alcohol 70%

water, Sterile

Definition SSI:

• A surgical wound infection occurs when

micro-organisms from the skin, other

parts of the body or the environment

enter the incision that the surgeon

makes through the skin

• Physical symptoms: pus, inflammation,

swelling, pain and fever.

• Etiology: Staphylococcus aurens is the

most common causative organism

A Major Surgical Site Infection

can be a Catastrophe

Sternotomy, unstable sternum,

mediastinitis

• Potential complications of SSIs:

1. tissue destruction

2. failure of the wound to close

properly resulting in incisional and

deep hernias

3. septic thrombophlebitis

4. recurrent pain

5. disfiguring and disabling scars

And

6. SSIs prolong the length of

hospitalization

Prevention of SSI

1. Tissue oxygenation

2. Bowel preparation

3. Treatment of remote infection

4. Skin preparation

5. Operating room environment

6. Operating room personnel

7. Antibiotic prophylaxis

8. Operative care

9. Incision care

MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins,

Philadelpia, pp 114-125

1.Tissue oxygenation

2. Bowel preparation

3. Treatment of remote infection

MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins,

Philadelpia, pp 114-125

Prevention of SSI

4. Skin preparation

MW Mulholland & GM Doherty (2006). Complications in Surgery, Lippincott Williams & Wilkins, Philadelpia, pp 114-125

1. Preoperative Shower

2. Hair Removal

3. Operating Room Skin Preparation

Prevention of SSI

s 4. Skin

preparation

5. Operating Room Environment

1. Ventilation

2. Room Surfaces

3. Instrument Sterilization

Prevention of SSI

6. Operating room personnel

1. Surgical Scrub

2. Surgical Garb and Gloves

3. Sterile Gloves and Gown

Prevention of SSI

Sterile??

7. Antibiotic prophylaxis ….. !

Prevention of SSI

Total Number of Operation and Antibiotic use at the Department of Surgery Dr. Soetomo Hospital

Year

Kind of Operation Antibiotic Use

Elective Emergency ∑ Non Prophylatic Theraupetic ∑

TOTAL

2004

2147

(64,7%)

1172

(35,3%)

3319

(100%)

1214

(36,6%)

1736

(52,3%)

369

(11,1%)

3319

(100%)

TOTAL

2005

2302

(68%)

1088

(32%)

3390

(100%)

1299

(38%)

1469

(43%)

622

(19%)

3390

(100%)

TOTAL

2006

2441

(64,9%)

1320

(35,1%)

3761

(100%)

1281

(34,1%)

2149

(57,1%)

331

(8,8%)

3761

(100%)

TOTAL

2007

2648

(66,4%)

1341

(33,6%)

3989

(100%)

1237

(31%)

2328

(58,4%)

424

(10,6%)

3989

(100%)

TOTAL

2008

2525

(67,5%)

1214

(32,5%)

3739

(100%)

995

(26,6%)

2289

(61,2%)

455

(12,2%)

3739

(100%)

TOTAL

2009

1547

(100%)

606

(28,02%)

1111

(71,36%)

436

(28%)

1547

(100%)

Since the introduction of benzylpenicillinabout 60 years ago, antimicrobial resistance is an increasing problem with nowadays sometimes serious consequences for the treatment of patients with infectious disease. Worldwide (multi) resistant bacteria like methicillin-resistant Staphylococcus aureus(MRSA), vancomycin-resistant enterococci(VRE), extended-spectrum brtalactamaseproducing (ESBL) Klebsiella pneumoniae, penicillin-resistant Streptococcus pneumoniae, Acinetobacter baumanniiagainst which colistine is the only effective treatment, and multiresistantMycobacterium tuberculosis, trouble patients, doctors and policy makers.

Prof. PJ Van Den Broek, 2005

Benefits Of Antibiotic Prophylaxis

Reduces the SSI and patient

morbidity

Reduces the duration and costs of

health care ( when the costs

associated with the management of

post operative infection are

considered, the cost – effectiveness

of prophylaxis becomes evident )

Shorten hospital stay.

Prophylactic Antibiotics in

Cardiac Surgery1. First-generation cephalosporin: - cefazolin (effectiviness against

gram-positiveorganism)

2. Second-generation cephalosporins: - cefamandole & - cefuroxime

3. Vancomycin is used if thre is a severe allergy to penicillin/ cephalosporin (+) amino glycoside: untuk gram-negative

Bacteriemie suspect : Rapid screening test for S. aureus/ culture

4. Mupirocin emperic treatment

(Superazon/ Beta laktamase)

Therapeutic Antibiotic

Indonesian colleagues seem not to

be aware of the hazardous

consequences of overuse and

misuse of antibiotics in their

patients.

Indonesia must be smarter in

handing out antibiotics

The Jakarta Post. Monday, August 20, 2007

Prof. Henri A. Verbrugh, Jakarta

http://www.thejakartapost.com/Archives/ArchivesDet2.asp?FileID=20070820.E03 (1 van 3)24-8-2007 17:30:09

8. Operative care:

1. Drains/ Dead Space Management

2. Tissue Handling

Prevention of SSI

9. Incision care

Prevention of SSI

Wound Care and Infectious Complications

B. Nosocomial Infections

2. Preventive measures that may reduce

the incidence of nosocomial infections

include:

a. Hand washing by the health care team

b. Chlorhexidine gluconate 0.12% oral rince

c. Early removal of invasive catheters, especially

central lines, upon suspicion of infection

(Robert M Bajor. Manual of Perioperative Care in Cardiac Surgery 4ed, 2005)

Wound Care and Infectious Complications

B. Nosocomial Infections

2. Preventive measures that may reduce the

incidence of nosocomial infections include:

d. Avoidance of empiric use of broad-spectrum

antibiotics and prolonged use when no longer

necessary

e. Aggressive ventilatory weaning protocols to

reduce the duration of mechanical ventilation

and other steps to avoid ventilator-associated

pneumonia.

f. Raising the threshold for blood transfusion

(transfuse if HCT < 26%)

(Robert M Bajor. Manual of Perioperative Care in Cardiac Surgery 4ed, 2005)

Prevention of Surgical Site

Infection

Preoperative

- Risk reduction

- Infection control

- Appropriate antibiotic prophylaxis

Intraoperative

- Infection control

- Maintain normoxia (?) and normothermia

- Maintain euglycemia (cardiac)

- Re-dose antibiotic if surgery > 4 hours

Prevention of Surgical Site

Infection

Postoperative

- Infection control

- Maintain normoxia (?) and normothermia

- Maintain euglycemia

- Do not administer additional antibiotics

- Certainly limit to no more than 24 h

- Remove drains/catheters as soon as

possible

Management of Superficial

Incisional SSI

OPEN the incision

Cultures not necessary if antibiotics not

indicated

Antibiotics not indicated if no or minimal

erythema/ no systemic toxicity

GENTLE local incision care

ALCOHOLS

Advantages Disadvantages

Broad spectrum

Effective against

• Most gram-positive

• Most gram-negative

• Fungi

• Viruses

Rapid acting

Short persistence

Potentially drying to skin

Potentially flammable

Spores may be resistant

Not applicable for mucosal

membranes

1. Larson EL. APIC guideline for handwashing and hand antisepsis in health care setting. Am J Infect control.

1995;23(4):251-266

2. Boyce JM. Pilted D Guideline for hand hygiene in healthcare settings. Recommendations of the healthcare

Infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force,

MMWR Recomm Rep. 2002 Oct 25;SI (RR-16):1-45

3. Crosby CT Mares AK. Skin antisepsis : past, present and future. JVAD. 2001: 1-6.

CHLORHEXIDINE

Advantages Disadvantages

Broad spectrum

Effective against

• Most gram-positive

• Most gram-negative

• Fungi

• Viruses

• Yeast

Highly persistent

Effective in the presence of organic

material (e.g.blood)

Minimally absorbed

Direct instilation can damage ears

or eyes

Direct contact with nerve tissue can

be damaging

Minimal activity against spores

1. Larson EL. Am J Infect Control. 1995:23(4):251-269

2. Hidalgo E. Domiguez C. Toxicol In Vitro. 2001;15(4-

5):271-276

3. Mald DG. et al Lancet. 1991:338:339-343

4. Larson E, Bobo L, J Emerg Med 1992;10(1):7-11

5. Boyce JM, et al. MMWR Recomm Rep. 2002 Oct

25: 51(RR-16):1-4

6. Anders N. Wollensak J. J Cataract Refract Surg.

1997;23(6):959-960

7. Perez R, et al Laryngoscope. 2000; 110(9); 1522-

1527

Organisms Cultured from SSIs

CHX-Alcohol Povidone-Iodine

Staph aureus 8 (7/0/1) 24 (12/2/2)

Staph epidermidis 5 (4/1/0) 7 (4/2/1)

Enterococci 6 (3/2/1) 6 (2/2/2)

Streptococci 1 (0/0/1) 10 (5/3/2)

E.Coli 3 (1/1/1) 1 (1/0/0)

Klebsiella 2 (1/0/1) 2 (1/0/1)

Bacteroides 7 (3/2/2) 5 (1/2/2)

Recommend to: DarouicheRO, Wall MJ Jr. Itani KMF, et al N Engl J Med 2010;362:18-26

Recommended Antibiotic

ProphylaxisSurgical Service Routine Antibiotic Allergy

Burns Cefazolin Clindamycin

Cardiac Cefazolin plus

Vancomycin

Vancomycin

Thoracic Cefazolin or

Cefuroxime

Vancomycin OR

Clindamycin

Colorectal Cefazolin plus

Metronidazole

Gentamicin plus

Clindamycin

General Surgery Cefazolin Clindamycin

Hepatobiliary

(complicated)

Ampicillin/Subbactam Gentamicin plus

Vancomycin

Plastic,Reconstructive &

Hand Surgery

Cefazolin Clindamycin or

Vancomycin

Vascular Cefazolin (add

Vancomycin if graft)

Vancomycin

Healthcare Associated Infection

(HCAIs) and resistant organisms

Urinary catheters ESBLsNDMs

Respiratory HAP VAP and ITU GRE

Vascular catheters and prosthetics MRCNS

Bacteraemias SSIs and cSSTIs MRSA

Clostridium difficile (CDI)

Antibiotic overuse

ASEPSIS

Additional treatment

Serous discharge

Erythema

Purulent exudate

Separation of deep tissues

Isolation of bacteria

Stay in hospital 14 days

Interval data

Definition of surgical site infection

Accurate audit

Surveillance MUST go to 30 days+

Unbiased blinded trained observer

Scoring systems

-if we are to have mandatory reporting who will

undertake it and who will pay?

MRSA screening

MRSA serious risk to

surgical patients screen

all elective patients?

Reduce bacterial load

(including MSSA?)

approoriate local

antimicrobial use

Classification of

Operative Wound

% SSI (+)

2005

% SSI (+)

2006

% SSI (+)

2007

% SSI (+)

2008

% SSI (+)

2009

TOTAL

2005-2009

(5 Years)

Clean

(Lit. IR: 1-5 %)

1.72%

(19/1101)

1.47%

(24/1637)

1.44%

(19/1328)

1.76%

(17/967)

1.59%

(17/1063)

1.57%

(96/6091)

Clean Contaminated

(Lit. IR: 8-11 %)

2.10%

(9/428)

2.74%

(97/1386)

2.29%

(24/1048)

2.23%

(86/673)

1.94%

(9/463)

2.37%

(95/3998)

Contaminated

(Lit. IR: 15-20 %)

2.22%

(1/45)

5.56%

(2/36)

7.50%

(3/40)

6.25%

(2/32)

4.88%

(4/82)

5.11%

(12/235)

Dirty & Infected

(Lit. IR: 27-40 %)

7.69%

(3/39)

9.75%

(4/41)

12.50%

(4/32)

8.33%

(3/36)

5.19%

(4/77)

8.00%

(18/225)

Total 1.97%

(32/1623)

2.19%

(68/3100)

2.04%

(50/2443)

2.17%

(37/1708)

2.02%

(34/1685)

2.09%

(221/10559)

Report of Surgical Site Infection (SSI) Period 2005-2009

Depart. of Surgery Dr. Soetomo Hospital Surabaya

* Data up-date Nov. 2010

* Surabaya, before 2003: ILO (SSI) 5.3%. Atlanta, USA: 1.5%

Report of SSI: 2005-2009

Division of Thoracic & Cardiovascular Surgery

Dr. Soetomo Hospital Surabaya - Indonesia

Case/Year 2005 2006 2007 2008 2009 TOTAL SSI %

Classification of Elective Operation

Clean 4/350 7/466 6/571 9/575 5/534 2496 31 1.24%

Clean Contaminated 1/31 0/32 0/3 1/28 0/8 102 2 1.96%

Contaminated 0/6 0/1 0/2 0/0 0/12 21 0 0%

Dirty 1/4 1/12 0/4 0/3 0/1 24 2 8.33%

Total 6/391 8/511 6/580 10/606 5/555 2643 35 1.32%

* Data up-date Nov. 2010

* To improve the use of antibiotics a major

change in behavior of prescribers of antibiotics

is needed.

* Results of SSI in physical symptoms as the body tries to fight the infection. There may be pus, inflammation, swelling, pain and fever.

* Four classification of operation:

1. clean operation

2. clean contaminated,

3. contaminated and 4. dirty.

Conclusion 1

* The patient should be assessed for factors

that can be corrected in the pre-op. period:

1. Shower with an antibacterial soap the night before the operation.

2. Must not be shaved the night before, as the risk as SSI is clearly increased by bacteria.

* Management of operating room, preparation of the skin, management of the incision including tissue handling, drain and wound treatment are important to patients.

*

Conclusion 2

2008 SSI symposium, Hong Kong

SSI : Balance?Patient factor

Operation

- shaving

- skin preparation

- surgical technique

- hypothermia

- foreign body

- prophylactic antibiotics

OR environment

CONCLUSIONS 3

The key to success is collaboration & efficiency. (John Hopkins Manual of Cardiac Surgical Care, 1997)

Thank

you