Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). A prevalence survey undertaken in 2006 suggested that approximately 8% of patients in hospital in the UK have an HCAI. SSIs accounted for 14% of these infections and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, prevalence studies tend to underestimate SSI because many of these infections occur after the patient has been discharged from hospital. SSIs are associated with considerable morbidity and it has been reported that over one-third of postoperative deaths are related, at least in part, to SSI. However, it is important to recognise that SSIs can range from a relatively trivial wound discharge with no other complications to a life-threatening condition. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic or keloid, persistent pain and itching, restriction of movement, particularly when over joints, and a significant impact on emotional wellbeing. SSI can double the length of time a patient stays in hospital and thereby increase the costs of health care. Additional costs attributable to SSI of between 814 and 6626 have been reported depending on the type of surgery and the severity of the infection. The main additional costs are related to re-operation, extra nursing care and interventions, and drug treatment costs. The indirect costs, due to loss of productivity, patient dissatisfaction and litigation, and reduced quality of life, have been studied less extensively.Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). A prevalence survey undertaken in 2006 suggested that approximately 8% of patients in hospital in the UK have an HCAI. SSIs accounted for 14% of these infections and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, prevalence studies tend to underestimate SSI because many of these infections occur after the patient has been discharged from hospital. SSIs are associated with considerable morbidity and it has been reported that over one-third of postoperative deaths are related, at least in part, to SSI. However, it is important to recognise that SSIs can range from a relatively trivial wound discharge with no other complications to a life-threatening condition. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic or keloid, persistent pain and itching, restriction of movement, particularly when over joints, and a significant impact on emotional wllbeing

1. PREPARED BY,
INTERN KRISHNA
KUMAR RAUT
SURGICAL SITE
INFECTION

2. Topics
 Definition
 Predisposing Factors
 Classification
 Assessment of Wound
 Prevention
 Treatment

3. DEFINITION
 An infection that occurs in surgical patient at the site of
operation is known as surgical site infection.
 The infection should occur within 30 days of surgery ( if
any implants are implanted - within one year )
 SSI is second most common complication following
surgical procedure , first being postoperative pneumonia

4. PREDISPOSING FACTORS
Agent
Host Environment

5. Agent
Staphylococcus aureus is the most common organism
isolated.
Enterococcus
E. Coli
Pseudomonas aurogenosa
Enterobacter spp.
Proteus
Klebsiella etc.

6. Host
Age
Diabetes Mellitus
HIV and Immunocompromised Status
Prolonged Steroid Therapy
Malnourished Patients
Smoking
Obesity
Associated comorbidities

7. Environment
Type of surgery / Wound
a) Clean 1-2 %
b) Clean contaminated <10%
c) Contaminated 15-20%
d) Dirty <40%
Duration of Surgery
Condition of Operation Theatre
Care of the Wound

8. Contaminated/ Unsterile instruments
Poor surgical technique (excessive blood loss,
hypothermia, tissue trauma, entry into a hollow
viscus, devitalized tissues …)
Inappropriate or untimely antimicrobial prophylaxis

9. Classification

10. Superficial incisional SSI
Infection occurs at the incision site within 30 days of
surgery and involves only skin or subcutaneous
tissue at the incision and at least one of the
following:
• purulent drainage from the superficial incision;
• an organism isolated by culturing fluid or tissue from
the superficial incision;

11.  deliberate opening of the wound by the surgeon
because of the presence of at least one sign or
symptom of infection (pain, tenderness, localized
swelling, redness or heat), unless the wound culture
is negative; or
• diagnosis of superficial incisional surgical site
infection by the surgeon or attending physician.

12. Deep incisional SSI
Infection occurs at the site of operation within 30 days
of surgery if no implant, and within 1 year of surgery
if an implant is left in place. Infection involves deep
soft tissue (muscle and fascia layers) and at least
one of the following:
• wound dehiscence or deliberate opening by the
surgeon when the patient has fever (> 38 °C) or
localized pain or tenderness, unless the wound
culture is negative;

13. • purulent drainage from deep incision but not from
the organ space component of the surgical site;
 an abscess or other evidence of infection involving
the deep incision seen on direct examination during
surgery, by histopathological examination or by
radiological examination;
• diagnosis of deep incisional surgical site infection by
the surgeon or attending physician.

14. Organ–space SSI
Infection occurs within 30 days of surgery if no implant
and within 1 year of surgery if an implant is left in
place. Infection involves any part of the anatomy
other than the incision that is opened or manipulated
during an operation and at least one of the following:
• purulent drainage from a drain placed through a stab
wound into the organ–space;

15. • an organism isolated from an aseptically obtained
culture of fluid or tissue in the organ or space
 an abscess or other evidence of infection involving
the organ or space seen on direct examination
during surgery, by histopathological examination or
by radiological examination;
• diagnosis of an organ–space surgical site infection
by the surgeon or attending physician.

16. Assessment Of Wound
1.Southampton wound grading system for healing
and infection:
 Grade 0 - normal healing;
 Grade 1 - bruising/mild erythema;
 Grade 2 - severe erythema with other features of
inflammation at or around wound;
 Grade 3 - serous or bloody discharge;
 Grade 4 - presence of pus or deep infection or
tissue breakdown or significant haematoma.

17. 2.ASEPSIS wound scoring
Parameters
Score
• Additional treatment
1. Antibiotics
10
2. Pus drainage
05
3. Wound debridement
10
• Serous discharge—

18. • Purulent fluid—
for 5 days of first 7 days of wound infection 0-10
daily
• Separation of deep tissues—
for 5 days of first 7 days of wound infection 0-10
daily
• Isolation of bacteria 10
• Stay in the hospital (in-patient)
more than 14 days due to infection 05

19. ASEPSIS scores range from 0 to 70, with the
following interpretation:
0–10, satisfactory healing;
11–20, disturbance of healing;
21–30, minor wound infection;
31– 40; moderate wound infection;
> 40, severe wound infection.

20. 3. NNIS risk index
The NNIS risk index is based three parameters:
1.The American Society of Anesthesiologists
(ASA) preoperative assessment classification,
reflecting the patient’s preoperative physical
status;
2. The duration of the procedure; and
3.The surgical wound class.

21. Prevention and Treatment
Information for patients and carers
 Offer patients and carers clear, consistent
information and advice throughout all stages of their
care. This should include the risks of surgical site
infections, what is being done to reduce them and
how they are managed.
 Always inform patients after their operation if they
have been given antibiotics.

22. Preoperative phase
 Advise patients to shower using soap, either the day
before, or on the day of, surgery.
 Do not use hair removal routinely to reduce the risk
of surgical site infection. If hair has to be removed,
use electric clippers on the day of surgery. Razors
increase the risk of surgical site infection.
 The operating team should remove hand jewellery,
artificial nails and nail polish before operations.

23. Antibiotic prophylaxis
 Give antibiotic prophylaxis to patients before:
1.clean surgery involving the placement of a
prosthesis or implant
2.clean-contaminated surgery
3.contaminated surgery.
 Do not use antibiotic prophylaxis routinely for clean
non-prosthetic uncomplicated surgery.
 Use the local antibiotic formulary and always
consider potential adverse effects when choosing
specific antibiotics for prophylaxis.
 Consider giving a single dose of antibiotic
prophylaxis intravenously on starting anaesthesia.
However, give prophylaxis earlier for operations in
which a tourniquet is used

24. Intraoperative phase
 The operating team should wash their hands prior to
operation using an aqueous antiseptic surgical
solution, wear sterile gowns.
 Prepare the skin at the surgical site immediately
before incision using an antiseptic preparation:
povidone-iodine or chlorhexidine are most suitable.

25.  Give patients sufficient oxygen during major surgery
and in the recovery period
 Cover surgical incisions with an appropriate
interactive dressing at the end of the operation.

26. Postoperative phase
 Use an aseptic non-touch technique for changing
wound dressings.
 Use sterile saline for wound cleansing up to 48 hours
after surgery.
 When surgical site infection is suspected give the
patient an antibiotic that covers the likely causative
organisms. Consider local resistance patterns and
the results of microbiological tests in choosing an
antibiotic.

27.  Optimise core body temperature as warmer
patients resist bacteria better.
 Blood glucose control is essential even to
nondiabetics as well.

28. Management of SSI
 All infected material and pus should be removed
from the wound site (debridement) .
 Sutures are removed to allow free drainage of
infected material.
 Infected fluid is sent for culture and sensitivity and
suitable antibiotics are started.
 Once wound shows signs of healing by healthy
granulation tissue, secondary suturing is done.

29. references
 Baily and love 26th ed.
 SRB’s Manual of Surgery
 https://www.nice.org.uk/guidance/cg74/chapter/1-
Guidance