Surgical site infections

Background and aims: Antibiotic prophylaxis in surgery is known to reduce the rate of surgical site infections (SSI) as well as shorten hospital stay. However, there is currently a scarcity of data on antibiotic prophylaxis and SSIs among African countries including Botswana. Consequently, this study aimed to address this. Methods: A prospective study involving 400 patients was carried out at a leading tertiary hospital in Botswana from 2014-2015. Patients’ demographic information, type of surgery performed and peri-operative use of antibiotics were documented. All enrolled patients were followed-up for 30 days post discharge to fully document the incidence of SSIs. Results: Median age of patients was 35.5 (25 – 50) years, with 52% female. There were 35.8% emergency and 64.2 % elective surgeries. The most common operations were exploratory laparotomy (25%), appendectomy (18.3%), excision and mastectomy (8%). Antibiotics were given in 73.3% of patients, mainly

One of the commonest surgical complications in pa- tients with pre-existing diabetes mellitus and hypergly- cemia is infection, with superficial surgical site infections (SSIs), deep wound infections, surgical space abscesses, urinary tract infections and pneumonia accounting for a large percentage of infectious complications. The Ameri- can Diabetes Association defines poorly controlled dia- betes as having a target HbA1c level of ≥8% [23]. Using this threshold, studies have shown a higher occurrence of postoperative wound infections in cardiac and ortho- paedic patients who had HbA1C levels of ≥8% [24, 25]. To optimize the care of the patient with diabetes and re- duce the risk of complications, a team-oriented approach to treatment is highly recommended [26–28].

Results: Coagulase-negative Staphylococcus spp. were most commonly detected (n=69, 50%), followed by fecal bacteria (n=46, 33.3%). In 23.2% of cases, no bacteria were detected despite clinical suspicion of an infection. Most patients suffered from degenerative spine disorders (44.9%), followed by spinal fractures (23.9%), non-degenerative scoliosis (20.3%), and spinal tumors (10.1%). Surgical site infections occurred predominantly within 3 months (64.5%), late infections after 2 years were rare (4.3%), in particular when compared with PJIs. Most cases were successfully treated after 1 revision surgery (60.9%), but there were significant differences between bacteria species. Fecal bacteria were more difficult to treat and often required more than 1 revision surgery.

I, Dr.J. Sulthana Dhilras., hereby declare that, I carried out this work on “ROLE OF PROPHYLACTIC ANTIBIOTIC TO PREVENT SURGICAL SITE INFECTIONS IN CLEAN SURGERIES” at the department of surgery, Govt. Rajaji Hospital, Madurai,under the guidance of Prof.Dr.S. Selvachidambaram,M.S., PROFESSOR OF SURGERY, during the period of June 2011 to June 2012. I also declare that this bonafide work has not been submitted in part or full by me or any others for any award, degree or diploma to any other university or board either in India or abroad.

BACKGROUND: Surgical site infections (ssi) are the third most commonly reported nosocomial infection and they account for approximately a quarter of all nosocomial infections. It has an adverse impact on the hospital as well as on the patient. It is responsible for increasing length of stay of patient which results in social and economic loss to the patients and family. Host factors, wound factors and surgery related factors are implicated in the causation of ssi. AIMS AND OBJECTIVES: 1) To study the incidence of ssi in our hospital.2)To study the risk factors of ssi in our hospital.3)To identify any change in the bacteriology of ssi .MATERIALS AND METHODS: 450 operated cases in surgery were included in this study. Certain risk factors like – type of surgical wound, elective or emergency surgery, antibiotic prophylaxis, duration of surgery, presence or absence of drain and any underlying or predisposing conditions were noted. Swabs were obtained from the post operative infected wounds and processed by the conventional microbiological methods. Antimicrobial susceptibility testing was done by kirby-bauer disc diffusion method and interpretation was done according to clsi guidelines.Statistical analysis was done by applying student t- test and the chi – square test of significance. RESULTS: The incidence of ssis following laparotomies is 22.2%. .emergency laparotomies were statistically more likely to develop ssi than elective laparotomies.a large share of abdominal ssis was occupied by surgeries with clean-contaminated wounds, which is similar to other studies. It reflects the higher proportion of such cases in laparotomies.diabetes mellitus was the most common co- morbidity encountered.increase in age, smoking , diabetes mellitus, obesity, hb < 10 gm %, copd, cancer , hiv/aids,asa grade,duratio of surgery > 2hrs,wound irrigation with saline,pre op stay > 5 days were the risk factors identified. The most common organism implicated in the development of abdominal ssi was mrsa, which is different from that noted in literature. CONCLUSION: Increased awareness among hospital staff with regard to infection control and strict adherence to the aseptic precautions is the need of the hour. The high rate of ssi with relative preponderance of mrsa strain calls for intensive infection control practices and routine surveillance of ssi in all hospital.

Surgical site infections (SSIs) are associated with any surgical procedure and represent a significant burden in terms of patient morbidity, inconvenience to surgeon and extended hospital stay.SSIs have been shown to compose upto 20% of all healthcare associated infections and constitute significant burden to healthcare services. Atleast 5% of patients undergoing surgical procedures develop SSIs. SSIs may range from spontaneous limited wound discharge to life threatening complications.

Surgical site infections (SSIs) are one of the most prevalent, and life-threatening, causes of healthcare-associated infections in the United States today. In 1996, it was reported that over 1.5 million SSIs occurred annually based on reports generated from the CDC and National Center for Health Statistics (Sage Products). Since then, according to one source in 2006 alone, an estimated 8% of patients in the hospital setting in the U.S. had developed a healthcare- associated infection, with SSIs accounting for 14% of these infections (U.S. National Library of Medicine, 2008). This statistical finding merely represents the reported SSIs while in the

Purpose: Analyses of risk factors associated with surgical site infections (SSIs) af- ter laparoscopic appendectomy (LA) have been limited. Especially, the association of an underweight body mass index (BMI) with SSIs has not been clearly defined. This study aimed to identify the impact of underweight BMI in predicting SSIs af- ter LA. Materials and Methods: The records of a total of 101 consecutive pa- tients aged ≥16 years who underwent LA by a single surgeon between March 2011 and December 2012 were retrieved from a prospectively collected database. The rate of SSIs was compared among the underweight, normal and overweight and obese groups. Also, univariate and multivariate analyses were performed to identi- fy the factors associated with SSIs. Results: The overall rate of SSIs was 12.8%. The superficial incisional SSI rate was highest in the underweight group (44.4% in the underweight group, 11.0% in the normal group, and 0% in the overweight and obese group, p=0.006). In univariate analysis, open conversion and being under- weight were determined to be risk factors for SSIs. Underweight BMI was also found to be a significant predictor for SSIs in multivariate analysis (odds ratio, 10.0; 95% confidence interval, 2.0‒49.5; p=0.005). Conclusion: This study dem- onstrated underweight BMI as being associated with SSIs after LA. Surgeons should be more cautious to prevent SSIs in patients that are underweight when performing LA.

Surgical site infections (SSI) are defined as infection occurring along the surgical wound within 30 days after surgery or within one year if an implant is used and left in place [1] [2]. They are categorized as incisional and organ/space infec- tions, with the former further classified as superficial and deep [2]. The former involves the skin and subcutaneous tissue while the latter affects tissues under- neath the deep fascia. Organ/Space infection involves organ manipulated or en- tered during the procedure and would include periprosthetic or peri-implant in- fections. The CDC has developed guidelines for the diagnosis of both incisional and organ/space infections [2]. Prevention of SSI in orthopaedic implant surge- ries is paramount to the surgeon since infections, particularly periprosthetic and peri-implant infections, cause substantial morbidity to the patient.

Healthcare today is challenged by the infectious and chronic diseases. The goal of high quality, cost effective and accessible care requires a competent workforce of healthcare professionals (Maharajan, Rajiah et al. 2017). The surgical site infections are known to be the second most common infections that are spread from nurses or doctors working in the surgical wards due to their carelessness or low level of knowledge and practice regarding prevention of the infection at surgical site. The rate of surgical site infections in developed countries is low ranging from 2% to 6.4% but in undeveloped countries its rate is going upward from 5.5% to 25%”(Dubberke, Gerding et al. 2008)

Surgical site infections (SSIs) account for 14-16 percent among all the hospital-acquired infections in patients undergoing surgery, and are the 3 rd most occurring nosocomial infections in patients. Among the patients undergone surgery, SSIs are the commonest nosocomial infections (1). SSI remains a matter of concern for surgical procedures leading to increased rate of morbidity and mortality, and also increases the economic burden (2). The major factor responsible for SSI is the balance between the bacterial burden at the site and the resistance against infection (3,4).

Herein we describe a strong association between SSIs and plate exposures. Infections of the head and neck following ablative surgery may lead to bacterial colonization of plates, resulting in biofilm formation, wound contamination and subsequent plate exposure requiring hardware removal to eliminate the nidus of infection [32]. Durand et al. recently reviewed their ex- perience of SSIs following head and neck free reconstruct- ive surgeries reporting 25% of their swabs growing normal oral flora, 44% gram-negative bacilli, 20% methicillin- resistant Staphylococcus aureus and 16% methicillin- sensitive Staphylococcus aureus [33]. The authors found that in 67% of cultures, at least one pathogen was found to be resistant to prophylactic antibiotics. These infections that are often difficult to treat corroborate our finding that surgical site infections may lead to plate exposure as they are often recalcitrant to antimicrobial therapy.

Surgical site infections increase patients’ morbidity and mortality. It increases the overall cost of the patient’s care. These costs are incurred through increased lengths of hospital stay, prices of materials for wound care, pharmacy costs for antibiotics, increased outpatient and emergency room visits, diagnostic labora- tory studies, reoperation rate, and physician expenses. Mortality can result from septicaemia and multiple organ failure or indirect consequence of prolonged admission, such as pulmonary embolism. The annual cost of treating SSI in the United States is $10 billion [10]. In Australia, the conservative estimate of annual direct healthcare costs of treating superficial wound complications following prosthetic joint replacement is $34 million [11].

Among the nosocomial infections surgical site infection accounts for about 38%.Of the surgical site infections, organ or spaces which were accessed during surgery are involved in one third, and two thirds were confined to incision made during the operation.

I declare that this dissertation entitled ‘PROSPECTIVE STUDY OF VARIOUS FACTORS INFLUENCING SURGICAL SITE INFECTIONS is a record of work done by me in the department of General Surgery, Thanjavur medical college, Thanjavur, during my Post Graduate Course from 2006-2009 under the guidance and supervision of my unit chief PROF. DR. T.KRISHNAMOORTHY, M.S., and professor and head of the depart ment PROF. Dr. G. AMBUJAM, M.S., F.I.C.S., I t i s s u b m i t t e d i n p a r t i a l f u l f i l l m e n t f o r t h e a w a r d o f M.S. DEGREE EXAMINATION- BRANCH I (GENERAL SURGERY) to be held in March 2009 under the Tamilnadu Dr. M.G.R. Medical University, Chennai. This record of work has not been submitted previously by me for the award of any degree or diploma from any other university.

appendectomy (n = 238; 5.1%), vascular surgery (n = 16; 0.3%), and other minor interventions on genitourinary tract (n = 10; 0.21%). The following 6 surgical procedures included also the laparoscopic technique: cholecistec- tomy (n = 438; 56%), appendectomy (n = 24; 10%), colon surgery (n = 18; 4.9%), abdominal hysterectomy (n = 15; 4.2%), hernia repair (n = 39; 3.6%), and gastric sur- gery (n = 6; 3.6%). Table 1 summarizes the main charac- teristics of the study population. All the above listed procedures were included in the surveillance program. One month before starting the study, for each participat- ing center, referent infection control personnel, including infection control practitioners, physicians, and nursing staff attended a training meeting on how to collect infor- mation and on patients' follow-up standardization. In-hospital SSI

for general abdominal operations masks are not required for the protection of the patient, particularly by staff members in theatre who are not directly assisting. Mask should be changed for each operation; reuse and manipulation simply contaminates the outside of the mask with skin commensals. Masks should be worn in prosthetic implant surgery. An efficient mask must be capable of arresting low velocity droplets. Paper masks should not be used. Disposable masks made of synthetic fibres are better. Surgical antifog masks with flexible nosebands are available; they follow facial contours and retain a high efficiency of filtration. Masks continue to be worn to provide protection for the wearer against blood borne viruses as part of a policy of universal precautions. Full face visors also afford similar protection (Kirk and Ribbans 2004).

For most mild infections, control can be achieved on outpatient basis with the help of oral antibiotics. But in severe infections, it is necessary to use parenteral antibiotics. Each patient requiring therapeutic antibiotics should be assessed daily for response to treatment. If no improvement is seen, one has to reevaluate choice of antibiotics. As the patient improves, clinician must decide when to stop antibiotic therapy. Although no specific duration of antibiotic therapy is advised, for most procedures, a general guide is to continue antibiotics until the patient has shown an obvious clinical improvement based on clinical examination and has had a normal temperature for 48 hours or more. Signs of clinical improvement include improved mental status, return of bowel function reduction of tachycardia and spontaneous diuresis.

analysis of randomized controlled trials showed that the use of first generation cephalosporin compared with no antibiotics decreased the risks for development of wound infections (Relative Risk [RR] 0.38; 95% confi- dence interval [CI] 0.28, 0.53) and endometritis (RR 0.42; 95% CI 0.33, 0.54) [35]. Further, lower rates of SSIs have been found with antibiotic administration of first generation cephalosporin prior to skin incision com- pared with administration after cord clamp [11, 36–39]. The meta-analysis by Constantine et al. reported the risk of endometritis was lowered significantly (RR 0.47; 95% CI 0.26, 0.85) [11]. Another publication of a ran- domized controlled trial showed lower rates of both wound infection (OR] 0.7; 95% CI 0.55, 0.90) and endo- metritis (OR 0.61; 95% CI 0.47, 0.79) when antibiotic prophylaxis was given prior to skin incision compared with after cord clamp [39].

Nearly 60 % of SSIs are diagnosed after discharge from the hospital. This percentage is rising as the post- operative stay in hospital is getting shorter and the num- ber of 1-day surgical procedures is increasing over time [8]. The Diagnosis Related-Group (DRG) system under- estimates the rate of SSIs because of the very early dis- charge of surgical patients. The exact incidence of SSIs is, therefore, difficult to determine. According to current literature, active SSI surveillance is useful in reducing the incidence of SSIs by surveillance-induced infection control efforts [9]. When any prosthesis is implanted into the body during general surgery, cardiac surgery, orthopaedics, etc., beside S. aureus, Coagulase-negative Staphylococci, especially S. epidermidis, may be the cause of severe infections that can necessitate removal of the prosthesis.