Surgical Site Infections (SSI)

According to a report by the International Nosocomial Infection Control Consortium (INICC) in 2012, overall 1.4 million people worldwide were suffering from nosocomial infections, and in India alone, the rate was over 25 per cent, with SSI occupying a significant share. The incidence is likely underestimated because of inadequate surveillance and incomplete post-discharge data. Extensive surveys have shown that 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 SSIs. 2 SSI can range from a fairly minor wound discharge with no other complications to a life- threatening condition. Other outcomes include poor scars that are cosmetically unacceptable and cause psychological stress. 3 SSI is, in most scenarios, a preventable HCAI, that can double the length of hospital stay and thereby increase the costs of healthcare, attributable to re- operation, extra nursing care and interventions, and drug treatment costs. There are, in addition, indirect costs due to loss of productivity, patient dissatisfaction and litigation, and reduced quality of life. 4,5 Abdominal surgical site infections are among the most common infectious complications in hospitalised patients and are associated with serious consequences for outcomes and costs. They account for up to 14 % of SSIs in studies conducted in developing countries, where there is no organised surveillance system to describe routine nosocomial infections. The present study aims to determine the frequency of surgical site infections in patients undergoing various abdominal surgical procedures, the associated risk factors, the organisms implicated and their sensitivity patterns, and the outcomes observed after treatment among inpatients in the general surgical wards.

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.

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 (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).

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].

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

AA reviewed and authored the topics of pre-operative baths, MRSA screening and decolonization, and surgical skin preparation, surgical prophylaxis. AW reviewed and authored the topics of epidemiology, antimicrobial impregnated sutures and post- operative wound management. AzA reviewed and authored the topic of glycemic control. HYL reviewed and authored the topics of risk factors for SSI, mechanical bowel preparation and oral antibiotics for elective colorectal surgery, and oxygenation. KM reviewed and authored the topics of surveillance of surgical site infections, normothermia, normovolemia and hair removal. KY reviewed and authored the topics of irrigation, drapes and laminar airflow. MLL is the lead author of this manuscript and chaired the workgroup discussion. She also reviewed and authored the topics on surgical hand preparation, nutrition and wound protector. Both AzA and KY reviewed and authored the topics of vancomycin powder. All authors read and approved the final manuscript.

completed by the quality improvements coordinator will include statistical comparisons of initial baseline information, to the new data that has yet to be collected and evaluated. Once such information is collected, a thorough analysis can be implemented to evaluate whether this new process has yielded the desired outcomes and if a reduction in surgical site infections has been accomplished. The quality improvements representative is presently working with corporate officials to gather such information and a meeting is scheduled for the last Friday of the month of April with the interdisciplinary team for the final evaluation step. With a low risk level and score of 44 on the FMEA analysis, the team expects much success with the new pre-op care process and a great reduction in SSIs within the microsystem.

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)

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.

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, 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.

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 (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.

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.

In addition to on-site validation visits, several other factors contribute to the optimization of the Dutch surveillance data. First, all ICPs in the Netherlands have finished a 1.5-year education program that includes courses in surveillance and basic epidemiology. Second, data received by PREZIES are checked for obvious mistakes by software that is especially developed for this purpose. For example, the wound contamination class must be between 1-4, the date of birth must be before date of surgery, and values of mandatory variables must be recorded. In addition, each year, before the national surveillance data are reported, review of the aggregated database is conducted, including confirmation that no men are reported as having had gynecological surgery performed, that no duplicate records are present, and that no SSIs were detected later than 30 days after surgery (or 365 days after surgery, for patients who received a nonhuman implant). Third, during yearly meetings for network participants, methodological points are discussed, participants’ experiences exchanged, and SSI case studies are presented and discussed. Since 2003, PREZIES has also organized a 1-day workshop for ICPs and other surveillance staff who are planning to start surveillance. During the workshop, PREZIES provides general information and tips about how to set up the surveillance. Fourth, PREZIES has a Web site on which general information, protocols, reference data, and news items are published. Surveillance staff can review SSI definitions by analyzing case studies that are published on the PREZIES Web site every 2 months. Fifth, PREZIES often publishes surveillance-related articles in the primary Dutch journal for ICPs (Tijdschrift Voor Hygiëne en Infectie Preventie). Finally, experiences are shared among participating hospitals through discussions on best practices, and PREZIES introduces ICPs from different hospitals in order to exchange knowledge.

For each patient, infection control personnel used a ques- tionnaire to collect information on demographic and operation specific characteristics, and on SSI occurrence. The following information was ascertained: demographic characteristics, dates of admission and discharge, opera- tion characteristics (i.e. type, date, and duration of the sur- gical procedure, emergency or elective surgical procedures, wound contamination class according to the four-point wound infection score of the National Research Council [19], American Society of Anesthesiolo- gists (ASA) physical status score [20], any use of endo- scopic surgical approach, any prosthesis implant), antimicrobial perioperative prophylaxis, presence of drains, occurrence, date of onset and type of in-hospital SSI.

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD – 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major

The infection of a wound can be defined as the invasion of organisms through tissues following a breakdown of local and systemic host defences, leading to cellulitis, lymphangitis, abscess and bacteraemia. Surgical site infection (SSI) has always been a major complication of surgery and trauma and has been documented for 4000-5000 years. Galen recognized that localization of infection in wounds, inflicted in the gladiatorial arena, often heralded recovery, particularly after drainage. The understanding of the causes of infection came in the 19th century. Microbes had been seen under microscope, but Koch laid down the first definition of infective disease known as Koch ’s postulates. Koch ’s postulates providing the agency of an infective organism: it must be found in considerable numbers in the septic focus, it should be possible to culture it in a pure form from that septic focus and it should be able to produce similar lesions when injected into another host. Louis Pasteur recognized that micro-organisms were responsible for spoiling wine, turning it into vinegar (Williams et al. 2008).

Dr Toltzis was a site participant in the SSI reduction program and was responsible for data analysis and the organization and composition of the manuscript; Dr O ’ Riordan was the statistician principally responsible for conducting the analyses; Dr Cunningham co-led the implementation of the SSI reduction program design and reviewed the manuscript drafts; Dr Ryckman participated in the conceptualization and development of the SSI reduction program and reviewed manuscript drafts; Ms Bracke provided statistical support throughout the implementation of the SSI reduction program and during manuscript preparation; Mr Olivea participated in the development of the design of the SSI reduction program and its implementation and reviewed manuscript drafts; Dr Lyren was a program leader for the statewide OCHSPS and conceptualized the quality assurance program and assisted in data collection at the statewide level and in the design of the manuscript; and all authors approved the fi nal manuscript as submitted. Presented in part at the 2011 Annual Meeting of the Pediatric Academic Societies, Denver, CO.