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Identify and Treat the Cause: 4.1 Assessment of Surgical Site Infections (SSI)


Classifications of Surgical Wounds1

 
Clean (1-2% infection rate)
  • Surgery does no enter colonized viscus or body cavity and there are no breaks in surgical technique
Clean-contaminated (6-9% infection rate)
  • Surgery does enter colonized viscus or body cavity but under elective or controlled conditions
Contaminated (13-20% infection rate)
  • Gross contamination at the operative site in the absence of clincal infection or there are breaks in surgical technique
Dirty/Infected (40% infection rate)
  • Active infection already present during surgical procedure
 

Categories of Surgical Site Infections (SSI)

Category 1
Superficial Incisional
  • Involves skin & subcutaneous tissue
  • Occurs within 30 days of surgery
  • Has at least 1 of the following:
    • Purulent drainage
    • Organism isolated from aseptic obtained culture
    • At least one of Pain/tenderness, localized swelling, redness or heat
    • Superficial incision opened by surgeon unless the incision culture is negative
      Diagnosis of a superficial incisional SSI by surgeon or attending DR/NP
Category 2
Deep Incisional
  • Involves deep soft tissue, including fascia and muscle
  • Occurs within 30 days of surgery in no implant used or within 1 year if implant is in place
  • Has at least 1 of the following:
    • Purulent drainage
    • Deep incision spontaneously dehisces or is deliberately opened by surgeon when patient has at least 1 of the following:
      • Fever > 38°C or localized pain
      • Evidence of infection (e.g. abscess) involving deep tissue found during examination, during re-operation or by histopathologic or radiologic examination
  • Diagnosis of deep incisional SSI by surgeon or attending DR/NP
Category 3
Organ/Space
  • Involves any part of the body that does not include deep tissue, muscle or fascia that has been opened or manipulated during surgery
  • Occurs within 30 days of surgery in no implant used or within 1 year if implant is in place
  • Has at least 1 of the following:
    • Purulent drainage from a drain that is placed through a stab sound into the organ/space
    • Organisms isolated from an aseptically obtained culture
    • Evidence of infection (e.g. abscess) involving organ/space found during direct examination, re-operation or by histopathologic or radiologic examination
  • Diagnosis of an organ/space SSI by surgeon or attending DR/NP

Acute Surgical Site Infection2 3
  • Rarely occur in the first 48 hours after surgery
  • Fever that may occur during first 48 hours may be due to non-infectious/unknown causes
  • Usually occur within 30 days of surgery
  • May occur up to a year after surgery if implant was used

Risk of antibiotic treatment4
  • Adverse drug reaction/allergy
  • Risk of C. difficile diarrhea
  • Antibiotic-resistance

First line of antibiotics5
  • Also called ‘empirical’ or ‘blind’ therapy
  • Should cover most likely infecting pathogen
  • Identify allergies
  • Patient’s clinical status including recent antibiotic history
  • Broad-spectrum covering staph aureus (most common cause of SSI)

After clean-contaminated surgery with mucosal surfaces6
  • Empirical antibiotic regimen that includes: Metronidazole, Amoxiclav or Pipercillin-tazobactam

Methicillin-resistant staph aureus (MRSA)
  • Should be treated with empirical antibiotic regimen that includes treatment against locally prevalent strains of MRSA

Culture and sensitivity reports
  • After reports have been received, review results to ensure proper coverage of antibiotics
 

Table 2: Treatment for Acute Surgical Site Infections

Treatment for Acute Surgical Site Infections
Under 48 hours
post-surgery

 
Soft tissue emergency

Urgent surgical consult

Consultation with pharmacist as necessary
Consider using:
  • Penicillin G and Clindamycin
  • Cefazolin and Metronidazole
  • Vancomycin and Metronidazole
Over 48 hours
post-surgery


 
Open wound and culture for microorganisms

Consider ultrasound to rule out abscess

 
For procedures conducted above waist consider using:
  • Cefazolin
  • Clindamycin
  • Vancomycin

For procedures involving abdomen, perineum, genitourinary tract or lower extremities consider using:
  • Cefazolin and Metronidazole
  • Cefazolin and Clindamycin
  • Clindamycin and Ciprofloxacin
  • Vancomycin and Metronidazole and Ciprofloxacin

Table 2: Treatment of Acute SSIs (adapted)7

Chronic Surgical Wound8 9
  • Deviates from expected sequence of tissue repair
  • May include infected or dehisced surgical wounds
  • Described as being ‘stuck’ in prolonged inflammatory phase
  • Exudate no longer beneficial (may block cell proliferation and degrade matrix in wound)

Chronic Surgical Site Infection10
  • Requires team approach
  • Treatment based on:
    • Duration of wound (usually over 1 month)
    • Location of wound
    • Type of infection
  • Surgical intervention may be required to:
    • Remove devitalized tissue or infected foreign material
    • Close a fistula
    • Drain or remove sinus tract
  • Multi-resistant microorganisms (MRSA, gram negative bacteria or fungi) may be involved
  • Long-term antibiotics may be required
  • Patients frequently require rehabilitation

  Increased localized pain is a significant predictor of deep compartment infection 
 

Table 3: Acute versus Chronic SSIs

 

 
Symptoms Signs

Acute Surgical Site Infection (<30 days)
 
 
  • Localized heat
  • Pain/tenderness
  • Redness
  • Swelling
  • Purulent drainage
  • Fever (>38.5)
  • Spontaneous dehiscence (category 2 or 3)
  • Wound opened by surgeon
  • Surgeon confirms SSI present
  • Abscess  may be present
Chronic Surgical Site Infection
(>30 days)
  • Pain
  • Decline in function
  • Fever may be absent
  • Lack of healing
  • Unresolved dehiscence
  • New sinus or fistula formation
  • Persistent wound drainage
  • Presence of foreign body
  • Presence of devitalized tissue
  • Poor local vascularity
  • Persistent odour
  • Absence of healing
  • Infected prosthetic implant

Table 3: Acute versus Chronic SSIs adapted 11

4.2 Risk Factors that can affect healing


Level C: RNAO's Interpretation of Evidence:

12

a. Risk Factors that may cause surgical wounds to open, develop infection or stall healing (DFUs)13

  • Diabetes
  • Obesity
  • Tobacco and nicotine use
  • Vascular status
  • Infection
  • Multiple co-morbidities
  • Medications
  • Renal failure
  • History of radiation treatments
  • Use of internal grafts/implants
  • Emergent surgery
  • Re-exploration of wound
  • Prolonged surgical time
  • Prolonged ventilation during surgery
  • Psychosocial factors (anxiety, depression, social isolation, low economic status and pain)
  • Use of blood products
  • Type of Surgery (i.e. clean, clean- contaminated, contaminated or dirty and infected)
  • Inappropriate use of cleansers or wound dressings
  • Coincident remote site infections
  • Systemic use of steroids
  • Extremes of age
  • Nutritional deficits
       

    b. Odds Ratio of Surgical Wounds NOT Healing in 24 weeks14

    A good prediction of healing is 20-40 % reduction in size within first 2-4 weeks. If acute surgical wounds fail to heal within 30 days, they are considered chronic wounds.

    Factors that may affect healing potential:

    Local

    • Presence of necrosis, foreign body and/or infection
    • Disruption of microvascular supply
    • Cytotoxic (toxic to cells) agents

    Host
    • Co-morbidities (i.e. inflammatory conditions, nutritional insufficiencies, peripheral vascular, renal, obesity or  coronary artery disease)
    • Adherence to plan of care by patient and caregivers
    • Cultural and personal belief systems

    Environment
    • Access to care and or offloading
    • Family support
    • Healthcare sector
    • Geographic surroundings
    • Socioeconomic status

    Medications that can affect healing include
    • chemotherapy
    • anticoagulants
    • antiplatelets
    • corticosteroids
    • vasoconstrictors
    • antihypertensives
    • diuretics
    • immunosuppressive drugs
    • Other medications used to treat acute episodic illnesses may affect healing
      (eg. antibiotics, colchicine, anti-rheumatoid arthritics)

    Predictors of delayed healing15
    • Tobacco and nicotine use
    • Poor nutritional status
    • Increased BMI
    • Wound bed too wet/desiccated causing a breakdown of extracellular matrix proteins and growth factors
    • Prolonged inflammation
    • Psychosocial factors (anxiety, depression, social isolation, low economic status and pain)
    • Wound bed temperature decrease
    • Infection
    • Edema
    • Seroma/hematoma/abscess
    • Wound tension
    • Wound trauma
    • Presence of drainage devices


    Identify and Treat Cause: 4.3 Complete a Holistic Assessment

     
    1. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    2. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    3. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
    4. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
    5. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
    6. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
    7. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    8. Excellence, National Institute for Health and Clinical. Surgical Site Infection - Prevention and treatment of surgical site infection. London, U.K. : Royal College of Obstetricians and Gynaecologists, 2008.
    9. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    10. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    11. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    12. Ontario, Registered Nurses Association of. Assessment and Management of Venous Leg Ulcers. Toronto : s.n., 2004.
    13. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    14. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.
    15. Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Orsted Heather L., Keast David H., Kuhnke Janet, Armstrong Pamela et al. 1, s.l. : Wound Care Canada, 2010, Vol. 8.

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