SURGICAL SITE INFECTIONS (SSI)
The common source of pathogens is the endogenous flora of the patient’s skin, mucous membranes, or hollow viscera. Therefore, the pathogens isolated from infection differ, primarily depending on the type of surgical procedure. In clean surgical procedures, in which the gastrointestinal, gynaecologic, and respiratory tracts have not been entered; Staphylococcus aureus from the exogenous environment or patient’s skin flora is the usual cause of infection. In other categories of surgical procedures, including clean contaminated, contaminated, and dirty, the polymicrobial aerobic and anaerobic flora closely resembling the normal endogenous microflora of the surgically excised organ are the most frequently isolated pathogens. Other sources of SSI pathogens are from distance focus such as in patients with prosthesis or implant place during the surgery, surgical personnel, operating environment, surgical tools, instruments, and materials brought to the field during an operation.
SURGICAL SITE INFECTION PREVENTION
Preparation of the patient:
1. Whenever possible, identify and treat all infections remote to the surgical site before elective operation and postpone elective surgeries on patients with remote site infections until the infection has resolved.
2. Keep preoperative hospital stays as short as possible while allowing for adequate preoperative preparation.
3. Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation.
4. If hair needs to be removed, it is done immediately before operation, preferably using electric clippers and not razor blade.
5. Adequately control blood glucose levels in all diabetic patients.
6. Encourage non-smoking /use of cigarettes, cigars, pipes, or any other form of tobacco consumption for at least 30 days prior to the surgery.
7. Do not withhold necessary blood products transfusion.
8. Encourage patients to shower or bathe at least the night before the operative day.
9. Use an appropriate antiseptic agent for skin preparation.
10. Apply preoperative antiseptic skin preparation in concentric circles moving towards the periphery. The prepared area should be large enough to extend the incision or create new incisions or drain sites, if necessary.
1. Administer a prophylactic antibiotic agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI for a specific operation.
2. Administer by IV route the initial dose of prophylactic antibiotic agent, timed such that a bactericidal concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until at most a few hours after the incision is closed in the operating room. In most cases, antibiotic should be given within 60 minutes before the incision and the antibiotics should be stopped within 24 hours after surgery.
Routine environment sampling of the Operation Room (OR) is not required. Perform microbiologic sampling of OR environment surfaces or air as part of an epidemiologic investigation.
Cleaning and disinfection of environmental surfaces
1. When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an operation, use approved hospital disinfectant to clean the affected areas before the next operation.
2. Do not perform special cleaning or closing of OR after contaminated or dirty operation.
3. Clean the operating room floor after the last operation of the day or night with an approved hospital disinfectant.
Asepsis and surgical technique
1. Adhere to principles of asepsis when intravascular devices, spinal or epidural anesthesia catheters, or when dispensing and administering intravenous drugs.
2. Assemble sterile equipment and solutions immediately prior to use
Sterilization of surgical instruments
Sterilize all surgical instruments according to guidelines.
Surgical attire and drapes
1. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation.
2. Wear a cap or hood to fully cover the hair on the head and face when entering the operating room.
3. Wear sterile gloves if a scrubbed surgical team member. Put on gloves after donning a sterile gown.
4. Using surgical gowns and drapes that are effective barriers when wet.
5. Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials.
Postoperative incision care
1. Protect with a sterile dressing 24 to 48 hours postoperatively an incision that has been closed primarily.
2. Wash hands before and after dressing changes and any contact with the surgical site.
3. Use sterile technique to change incision dressing.
4. Educate the patient and family regarding proper incision care, symptoms of surgical site infection, and the need to report such symptoms.
Develop a good surveillance system to study the incidence of SSI.
1. Use standardized case definitions without modifications for identifying SSI among surgical inpatients and outpatients.
2. Use methods for inpatient and outpatient case-finding that accommodate available resources and data needs.
3. Assign surgical wound classification upon completion of an operation.
4. For each patient undergoing an operation chosen for surveillance, record those variables shown to be associated with increased SSI risk, such as surgical wound class and duration of operation.
5. Periodically calculates operation-specific SSI rates stratified by variables shown to be associated with increased SSI risk.
6. Report stratified operation-specific rates to surgical team members.