ABSTRACT

Surgical Site
Infections are the
third most
NOSOCOMIAL commonly reported
nosocomial infection
INFECTION which has an adverse
Impact on the
hospital as well as on
(SURGICAL the patient. A
continuous
SITE surveillance is called
for, to keep a check

INFECTION) on the occurrence of

Surgical Site
Infection.

Administrator
Ms R Lumingu
Table of Contents

NOSOCOMIAL INFECTION .............................................................................................................................. 2

SURGICAL SITE INFECTION ............................................................................................................................. 2
INTRODUCTION .......................................................................................................................................... 2
CAUSES ....................................................................................................................................................... 2
SIGNS/SYMPTOMS ......................................................................................................................................... 3
RISK FACTORS ................................................................................................................................................ 4
DIAGNOSIS ..................................................................................................................................................... 5
COMPLICATIONS ............................................................................................................................................ 6
Wound Dehiscence ................................................................................................................................... 7
Hematomas ............................................................................................................................................... 7
Seromas ..................................................................................................................................................... 8
TREATMENT ................................................................................................................................................... 8
PREVENTION .................................................................................................................................................. 9
Conclusion....................................................................................................................................................10
References ...................................................................................................................................................11
NOSOCOMIAL INFECTION
SURGICAL SITE INFECTION

INTRODUCTION
Nosocomial infections also referred to as healthcare associated infections (HAI), are infections
acquired during the process of receiving health care that was not present during the time of
admission. They may occur in different areas of healthcare delivery, such as hospitals, long term
care facilities, and ambulatory settings, and may also appear after discharge. Healthcare
associated infections also include occupational infections that may affect staff. Infection occurs
when pathogens spread to a susceptible patient host.
There are different types of nosocomial infections such as central line associated blood stream
infections(CLABSI) , catheter associated urinary tract infections(CAUTI) ,surgical site
infections(SSI) , ventilator associated pneumonia(VAP) .
In this presentation we will mainly focus on Surgical Site Infection.
Surgical site infections are defined as infections occurring up to 30 days after surgery (or up to
one year after surgery in patients receiving implants) and affecting either the incision or deep
tissue at the operation site.
These type of infections occur in approximately 0.5% to 3% of patients undergoing surgery and
are among the most prevalent healthcare acquired infections.

CAUSES
How are SSIs caused?
There are a number of ways SSIs can be caused:
Endogenous infection: The majority of SSIs are caused by an endogenous infection, which is
when the incision becomes contaminated with microorganisms derived from the patient’s skin
or from an opened internal organ.
Exogenous infection: Exogenous infection occurs when external microorganisms contaminate
the operative site during the procedure. Sources include surgical instruments, the theatre
environment and the air. External microorganisms can also contaminate the wound at the time
of incident, or gain access to the wound following surgery, before the wound has healed.
Other causes of SSI
More rarely, SSIs can be caused by a distant source of infection within the body. In this
instance, the microorganisms from the infection attach to a prosthesis or other artificial implant
within the operative site. This is often referred to as haematogenous seeding or spread. In
prosthetic surgery involving an artificial implant, the presence of the foreign body can increase
the risk of SSI.
These prosthetic infections are biofilm-correlated as they are highly resistant to antibiotic
treatment. This is why antibiotic cements and antibiotic-coated implants are applied, as it helps
to reduce the risk of prosthetic-related infection by slowly releasing antibiotics.

SIGNS/SYMPTOMS
The signs and symptoms of surgical site infection can vary depending on the severity of
infection but they generally include:
• redness
• swelling,
• wound drainage
• shaking chills
• high fever
These are other signs and symptoms for specific types of surgical site infection:
Superficial incision surgical site infection may produce pus from the wound site. Samples of the
pus may be grown in a culture to find out the types of germs that are causing the infection.
A deep incisional surgical site infection may also produce pus. The wound site may also reopen
on its own or the surgeon may reopen the wound and find pus inside the wound.
An organ or space surgical sit infection may show a discharge of pus coming from a drain
placed through the skin into a body space or organ. A collect of pus called an abscess is an
enclosed area of pus and disintegrating tissue surrounded by inflammation. An abscess may be
seen when the surgeon reopens the wound or by special X-Ray studies.
It is important to note while these signs and symptoms could indicate a surgical site infection,
they can be cause by other factors. If you suspect you have a surgical site infection, it advisable
to contact your health care provider for proper diagnosis and treatment. Early intervention can
help prevent the infection from worsening

RISK FACTORS
Different factors determine the risk of a patient developing a surgical site infection and there
are four factors we need to consider:

• Patient
 • Environment a patient is being operated in.
• Operative factors
• Treatment for the patient
The table below shows some risk factors associated with each factor:

Patient Operative factors Environment Treatment

Age Previous surgery Poor ventilation Drains
Sex Blood loss
Poor sterilization Hypothermia
Nutritional indices Length of operation
Weight Antimicrobial sutures Inadequate skin prep Skin closure

Recent operation Operating surgeon

Contamination Lack antibiotics
Anemia Diathermy
Steroids Poor hygiene Oxygenation

Skin disease
hospitalization
Chronic inflation
Diabetes

DIAGNOSIS
Usually infections happen around day four or five and this can be seen by factors such as:
• Tenderness
• Edema (swelling around the wound)
• Warmth
• Pain
• Erythema
The major clinical exception to an infection that happens within the first 24 hours.
Can be caused by 2 bacteria:
• Streptococcus Pyogenes
• Clostridium perfringens
This can be a huge necrotizing infection that is a huge threat to life. A patient with rapid spread
of erythema, tenderness, edema, warmth & pain huge around wound should start treatment as
soon as possible. Negligence to these symptoms progress to systemic inflammatory response
syndrome (SIRS) and sepsis.
The diagnosis of a surgical site infection typically involves a combination of clinical assessment,
physical examination, and sometimes laboratory tests. Here's how the diagnosis process
generally works:
1. Clinical Assessment: Healthcare providers will review your medical history, surgical details,
and any symptoms you're experiencing. They will ask about pain, redness, swelling, fever, and
any changes in the wound.
2. Physical Examination: A thorough examination of the surgical site will be conducted. The
healthcare provider will look for signs of infection such as redness, swelling, warmth, drainage,
and tenderness.
3. Laboratory Tests: In some cases, laboratory tests may be ordered to confirm the presence of
infection. These can be:
• Blood Tests: Complete Blood Count (CBC) to check for elevated white blood cell count,
which can indicate an infection, and C-reactive protein (CRP) levels, which can rise in
response to inflammation.
• • Wound Culture: A sample of the wound drainage may be collected and sent to a
laboratory to identify the specific bacteria causing the infection. This helps determine
the appropriate antibiotic treatment
4. Imaging: In severe cases or when deeper infections are suspected, imaging studies such as X-
rays, ultrasound, or MRI might be used to assess the extent of the infection and its impact on
underlying tissues.
5. Clinical Criteria: Healthcare professionals might use established clinical criteria, such as those
provided by centers for disease control and prevention to aid in diagnosis of SSI.

COMPLICATIONS
Despite modern precautions and protocols in place, surgical site infection (SSI) continues to be
a risk. Additionally, SSIs can increase hospital length of stay by up to 9.7 days. Other
complications of surgical wounds include osteomyelitis, gangrene, periwound dermatitis,
periwound edema, wound dehiscence, and hematomas.
Wound Dehiscence
Dehiscence is a condition in which the surgical site gradually comes apart or becomes
completely open in response to various factors, such as poor suturing, stress on the wound
area, a compromised immune system, or infection. Signs of dehiscence in a surgical wound are
pain, redness, swelling, bleeding, drainage, and a feeling of sudden painful pulling.

Hematomas
Hematomas are not as common after surgery as SSIs or wound dehiscence; however, when
they do occur, they may lead to infection and/or wound dehiscence. A hematoma is a collection
of clotted or non clotted blood outside of the blood vessel (artery, capillary, vein) that spreads
into tissues. Symptoms of hematoma in a surgical wound are headache, neurological problems
(weakness on one side, difficulty speaking, confusion), nail pain, and abdominal pain.
Hematomas can take one to four weeks to resolve.
Seromas
A seroma develops when sterile, clear bodily fluids build up under the skin at the SSI site. There
may be swelling, pain, and tenderness. This complications can occur one to two weeks after
surgery. Although seromas are generally not dangerous, they may need to be treated by
draining with a syringe and needle or by placing a drain.

TREATMENT
Antibiotics: Antibiotics are often the first line of treatment. The choice of antibiotic depends on
the type and severity of the infection. Broad-spectrum antibiotics may be initially prescribed
until culture and sensitivity test results are available to pinpoint the specific bacteria causing
the infection.
Culture and Sensitivity Tests: These tests help identify the exact bacteria responsible for the
infection and determine which antibiotics will be most effective. Once results are available,
treatment may be adjusted accordingly.
Surgical Debridement: In cases of severe infection or the presence of necrotic (dead) tissue,
surgical debridement may be necessary. This involves the removal of infected or damaged
tissue to promote healing.
Drainage: If there's an accumulation of pus or fluid within the wound, drainage may be
required. This helps to reduce the bacterial load and facilitates the healing process.
Wound Care: Proper wound care is essential. This includes regular cleaning with mild soap and
water, followed by the application of an appropriate dressing. Dressings may need to be
changed regularly to maintain a clean and moist wound environment.
Pain Management: Pain management is important to ensure patient comfort during the
healing process. Over-the-counter or prescription pain medications may be prescribed.
Diabetes Control: If the patient has diabetes, it's crucial to maintain proper blood sugar
control, as uncontrolled diabetes can hinder wound healing and increase the risk of infection.

PREVENTION
Certain measures should be practiced in the emergency room to prevent these surgical site
infection and these include:
• Sterile technique: Healthcare providers should use sterile technique when performing
surgery to reduce the risk of infection.
• This includes wearing sterile gowns, gloves, and masks, as well as using sterile
instruments and following sterile technique.
• Patient preparation: Patients should be in good health before surgery to reduce the risk
of infection, including stopping smoking and limiting alcohol use.
• Adequate wound care: Proper wound care after surgery can help prevent infection. This
may include cleaning the wound, changing dressings, and taking prescribed medications.
Preventing SSIs requires a combination of efforts from healthcare providers and
patients. By following these guidelines, the risk of SSIs can be greatly reduced.
• Proper hand hygiene: Healthcare providers should wash their hands before and after
surgery to reduce the risk of infection. Patients should also be encouraged to follow a
hand and wound hygiene protocol
Conclusion
Given that SSIs are the most common and costly of hospital-acquired infections, there should
be adherence to guidelines and recommendations to reducing SSI occurrence. It is important
when assessing patients with risk factors that interventions are implemented and education is
provided before discharge home to promote better long term outcomes.
References
Beauchamp, 2022. Sabiston textbook of surgery. 21 ed. New York: Elsevier.

David Voet, Charlotte W. Pratt, 2016. Fundamentals Of Microbiology. 5 ed. Hoboken: John Wiley & Sons.

Pfunta A, 2021. Surgical Site Infections. 1(2011), p. 7.