Surgical Site

Infections
By Unit 1 PGs
WHAT IS SURGICAL SITE
INFECTION?
• A surgical site infection is an infection that occurs
after surgery in the part of the body where the
surgery took place.
It leads to
• Increased duration of hospital stay (7 days on an
average)
• Increased Morbidity
• Increased Mortality
Introduction

• Surgical site infection account for 29% readmissions

following hysterectomy.
• Patient's experiencing SSI are 60% more likely to
spend time in intensive care unit and have 2-11 times
higher risk of death compared to those without an SSI
• Surgical site infections are the third most frequently
reported nosocomial infections among hospitalised
patients.
• Advances in infection control practices include
improved operating room ventilation, sterilization
methods, barriers, surgical technique, and
availability of antimicrobial prophylaxis.
TYPES OF SSI’s
• 1. Incisional SSI
a. Superficial incisional SSI
b. Deep incisional SSI
• 2. Organ/Space SSI
Superficial incisional
SSI
• Infection occurs within 30 days after surgical procedure
AND
• Involves only skin and subcutaneous tissue of the
incision
AND
• Patient has at least 1 of the following:
a. Purulent drainage from the superficial incision
b. Organism isolated from an aseptically-obtained
culture of fluid or tissue
[Link] has at least one of the following signs or
symptoms: pain or tenderness, localized swelling,
redness, heat
 Deep Incisional SSI
• Infection occurs within 30 days after the operation if no implant
is left in place or within 1 yr. if implant is in place and the
infection appears to be related to the operation.
AND
• Involves deep soft tissues of the incision, e.g., fascial & muscle
layers
AND
• Patient has at least 1 of the following:
a. Purulent drainage from deep incision
b. Deep incision spontaneously dehisces or opened by surgeon
and is culture positive or not cultured and fever>38C ,localized
pain or tenderness.
c. Abscess or other evidence of infection found on direct exam,
during invasive procedure, by histopathologic exam or imaging
test.
 Organ Space SSI
• Infection occurs within 30 days after the operation if no implant is
left in place or within 1 yr. if implant is in place and the infection
appears to be related to the operation.
AND
• Infection involves any part of the body, excluding the skin incision,
fascia, or muscle layers that is opened or manipulated during the
operative procedure
AND
• Patient has at least 1 of the following:
a. Purulent drainage from drain placed into the organ/space
b. Organism isolated from an aseptically-obtained culture of fluid
or tissue in the organ/space
c. Abscess or other evidence of infection found on direct exam,
during invasive procedure, or by histopathologic or exam or
imaging test
Superficial surgical site Deep surgical site infection
infection

Organ/space site
infection
 Wound Class
Wound Class Description Examples Risk of Infection (%)

Wounds that are

uninfected, with Surgical incision (non-
Class I: Clean minimal risk of traumatic) made in a 0 - 2%
infection, and created sterile environment.
under sterile conditions.

Wounds that are

surgically created but Gastrointestinal surgery,
Class II: Clean- involve a controlled urinary tract surgery,
3 - 5%
Contaminated entry into a body part respiratory tract surgery
that normally has (without infection).
bacterial flora.

Wounds that are Open fractures, fresh

created in conditions lacerations, ruptured
Class III: Contaminated where contamination appendix, or surgical 10 - 20%
occurs, such as a procedures with spillage
traumatic injury. of contents.

Wounds that are

infected or highly Abscesses, traumatic
Class IV: Dirty or contaminated, usually wounds with dirt or
25 - 40%+
Infected showing signs of foreign objects, infected
infection at the time of surgical site.
the procedure.
Clean wound Contaminated
wound

Clean
contaminated
wound

Dirty wound
Further classification
• SEVERITY
MINOR:
discharge without cellulitis or deep tissue
destruction
MAJOR:
Pus discharge with tissue breakdown.
Partial or total dehiscence of the deep fascial layers of
wound.
Systemic illness is present
a) Early
Infection presents within 30 days of procedure
b) Intermediate
Occurs between one and three months
c) Late
Presents more than three months after surgery
Wound Assessment
Enable surgical wound healing to be graded
according to specific criteria, usually giving a
numerical value, thus providing more objective
assessment of the wound.

• ASEPSIS
• SOUTHAMPTON
ASEPSIS Wound Scoring
System
Criterion Description Points
A Additional treatment Antibiotics 10
Drainage of pus under local
5
anesthetics

Debridement of wound
10
(General anesthetics)

S Serous discharge Daily 0-5

E Erythema Daily 0-5
P Purulent exudates Daily 0-10
S Separation of deep tissues Daily 0-10
I Isolation of bacteria 10
S Stay in hospital prolonged over 14 days 5

• Score 0–10: satisfactory healing

• 11–20: disturbance of healing
• 20–30: minor wound infection
• 31–40: moderate wound infection
• >41: severe wound infection
SOUTHAMPTON Scoring System
SENIC Risk Index
Risk Factor Point(s)
Abdominal surgery 1
Surgery lasting more than 2 hours 1
A contaminated or dirty-infected surgical wound classification (Class
1
III or IV)

Presence of three or more diagnoses at the time of discharge 1

SENIC Score Risk of Infection

0 1%
1 3.6%
2 9%
3 17%
4 27%
 MICROBIOLOGY
• According to data from the NNIS system, the
distribution of pathogens isolated from SSIs has not
changed markedly during the last decade.
• Staphylococcus aureus, coagulase-negative
staphylococci,Enterococcus spp., and Escherichia coli
remain the most frequently isolated pathogens.
• An increasing proportion of SSIs are caused by
antimicrobial-resistant pathogens, such as
methicillin-resistant S. aureus (MRSA),or by Candida
albicans.
• From 1991 to 1995, the incidence of fungal SSIs
among patients at NNIS hospitals increased from
0.1 to 0.3 per 1,000 discharges
Organisms isolated in surgical
site infections in GGH,Kakinada
Pathogenesis
• The risk of SSI can be conceptualized according to the
following relationship
• Micro-organisms are normally prevented from causing
infection in tissues by
Mechanical: intact epithelium
Chemical: low gastric pH;
Humoral: antibodies, complement pathway and
opsonins ;
Cellular: phagocytic cells, macrophages,
polymorphonuclear cells and natural killer lymphocytes
These factors may be compromised by any comorbid
condition of the patient , surgical intervention and
treatment leading to SSI
Sources of infection
Endogenous
Exogenous
Distant spread
 Endogenous:
• For most SSIs, the source of pathogens is the
endogenous flora of the patient’s skin, mucous
membranes , or hollow viscera.
• These organisms are usually aerobic gram-positive
cocci (e.g., staphylococci), but may include fecal flora
(e.g., anaerobic bacteria and gram negative aerobes)
when incisions are made near the perineum or groin.
Exogenous: Staphylococci

• Exogenous sources of SSI pathogens include surgical

personnel the operating room environment and all
tools, instruments, and materials brought to the
sterile field during an operation.
• Exogenous flora are primarily aerobes ,especially
gram-positive organisms (e.g., staphylococci and
streptococci).Fungi from endogenous and exogenous
sources rarely cause SSIs.
Distant spread:
• Seeding of the operative site from a distant focus of
infection can be another source of SSI
pathogens,particularly in patients who have a
prosthesis or other implantplaced during the
operation.
• Such devices provide
a nidus for attachment
of the organism
Gram negative bacteria
Produce endotoxin

Cytokine production

Systemic inflammatory
response

Multi organ disfunction

syndrome
• Some bacterial surface
components, notably
polysaccharide capsules,
inhibit phagocytosis.
• Certain strains of
clostridia and
streptococci produce
potent exotoxins that
disrupt cell membranes
or alter cellular
metabolism.
• A variety of microorganisms , including gram-
positive bacteria such as coagulase-negative
staphylococci, produce glycocalyx and an
associated component called “slime",which
physically shields bacteria from phagocytes or
inhibits the binding or penetration of antimicrobial
agents.
RISK FACTORS
Patient

Age Nutritional status Diabetes

Coexistent
Smoking Obesity infections at a
remote body site

Colonization with Altered immune Length of

microorganisms response preoperative stay
Operation
Pre Operative Intra Operative Post Operative
• Preoperative • Duration of • Foreign material in
shaving operation the surgical site
• Preoperative skin • Operating room • Surgical drains
prep ventilation • Poor Wound Care
• Antimicrobial • Inadequate • Non compliance
prophylaxis sterilization of with anti biotics
• Duration of instruments
surgical scrub • Surgical technique
• Poorhemostasis
• Failure to
obliterate dead
space
• Tissue trauma
Diabetes
Increased blood glucose levels >200mg/dl in the
immediate postoperative period (<48hours) were
associated with increased risk of surgical site
infection.
Obesity
Hyperglycemia and Insulin Resistance:

• Obese individuals are more likely to have insulin resistance or diabetes.

• Hyperglycemia promotes bacterial growth and impairs neutrophil function.

Increased Stress on Surgical Sites :

• Obesity increases mechanical stress on incisions, leading to:

• Wound dehiscence (wound reopening).
• Higher risk of infection due to increased surface area for microbial growth.

Poor Vascularization and Oxygenation :

• Adipose tissue has limited blood supply, causing poor oxygen delivery to the surgical site.
• Hypoxia at the wound site delays fibroblast activity and collagen synthesis, impairing wound healing.

Impaired Immune Function

• Adipose tissue produces pro-inflammatory cytokines (e.g., TNF-α, IL-6), leading to chronic low-grade
inflammation.
• Excessive fat suppresses the immune response, reducing the ability to fight infections.

Prolonged Operative Time:

• Surgery in obese patients often takes longer due to technical challenges (e.g., accessing deeper tissues)
• Prolonged exposure increases the risk of contamination.
Malnutrition
Impaired Collagen Synthesis and Tissue Repair:

• Protein Deficiency
• Vitamin C Deficiency

Weakened Immune Function:

• Reduced Lymphocyte Production

• Zinc Deficiency

Hypoalbuminemia andEdema:

Malnourished patients often have hypoalbuminemia, reducing oncotic pressure and causing tissue
edema.
• Edema impairs oxygen and nutrient delivery to the surgical site, promoting bacterial growth.

Delayed Inflammatory Response:

• Impaired Cytokine Production

• Impaired Neutrophil Function

Poor Angiogenesis:

• Deficiency in micronutrients like iron and copper impairs angiogenesis, reducing oxygen delivery
to the wound site and delaying healing.
Immunocompromised
Status
Impaired Innate Immune Response:

• Decreased Neutrophil Function

• Altered Cytokine Production
• Compromised Skin Barrier

Impaired Adaptive Immune Response:

• Reduced Lymphocyte Activity

• Loss of Immunological Memory

Delayed Wound Healing

• The inflammatory phase of wound healing is prolonged due to reduced immune cell recruitment.
• Fibroblast activity and collagen deposition are delayed, weakening tissue repair and increasing susceptibility to
infections.

Increased Susceptibility to Opportunistic Pathogens:

Immunocompromised individuals are more prone to infections from normally harmless microorganisms (e.g.,
Candida, Pseudomonas).
• Antibiotic-resistant strains (e.g., MRSA) are more likely to colonize and infect immunocompromised patients.

Chronic Inflammatory States:

• Conditions like HIV and cancer can create a state of chronic inflammation that disrupts normal immune responses
and delays tissue repair.
Preoperative antiseptic
showering
• Preoperative antiseptic showering decreases the
skin microbial colony count.
• However they have not definitively shown to
reduce the SSI rates.
Preoperative hair removal
• Preoperative shaving of the surgical site the night
before an operation is associated with a
significantly higher surgical site infection risk than
either the use of depilatory agent or hair removal.
• The is because microscopic cuts in the skin , that
later serve as foci for bacterial multiplication
• Shaving immediately before the operation
compared to shaving within 24hrs preoperatively is
associated with decreased SSI rates.
• Clipping hair immediately before an operation has
been associated with a lower risk of SSI than with
shaving or clipping the night before an operation.
• Use of depilators has been associated with a lower
surgical site infection risk than shaving oe clipping
however depilators sometimes produce
hypersensitivity reactions.
Patient skin preparation in
operative room
• Both chlorhexidine gluconate and iodophors have
broad spectrum of antimicrobial activity
• Alcohol – readily available , inexpensive and
remains most effective and rapid acting skin
antiseptic
• Disadvantage of use of alcohol in operating room is
inflammability
 Preoperative hand or
forearm antisepsis

Members of the surgical team

should wash their hands and
forearms by scrubbing
immediately before wearing
sterile gowns and gloves.
• Ideally the optimum antiseptic used for this scrub
should have a broad spectrum activity, fast acting
and have a persistent effect.
• Scrubbing for atleast 2 minutes is as affective as
traditional 10minutes scrub in reducing hand
bacterial colony count
• Surgical team member who wears artificial nails
may have increased bacterial and fungal
colonization of hands despite of performing an
adequate hand scrub.
Management of infected or
colonised surgical
personnel
• Healthcare organisation implement policies to
prevent transmission of microorganisms from
personnel to patient
• This policies should address management of job
related illness , provision of postexposure
prophylaxis after job related exposure and when
necessary exclusion of ill personnel from work or
patient contact
Antimicrobial prophylaxis
• Principles must be followed to maximise the benefit
of antimicrobial prophylaxis
1. Use an antimicrobial prophylaxis agent for all
operations or classes of operations in which its use
has been shown to reduce the surgical site
infection rate based on evidence from clinical
trails.
2. Use an antimicrobial prophylaxis agent that is
safe,inexpensive and bactericidal with an invitro
spectrum that covers the most probable
intraoperative contaminants for the operation
• Time of infusion of the initial dose of antimicrobial
agent so that a bactericidal concentration of the
drug is established in the serum and tissues by the
time skin is incised
• Maintain therapeutic levels of antimicrobial agent
in both serum and tissue throughout the operation
and until at next few hours after the incision is
closed in the operating room.
Antimicrobial prophylaxis regimens for procedures:
• Clindamycin or vancomycin are used in penicillin
allergic patients
• In addition clindamycin , metronidazole should be
included to ensure anaerobic coverage
• Vancomycin is used as agent of choice in MRSA
• When duration of operation is exceed the time in
which therapeutic level of antimicrobial agent can
be maintained , additional antimicrobial
prophylaxis agents must be infused.
Intraoperative
Issues
Operating room
environment
VENTILATION:
• Operating room air may contain microbial laden
dust,lint or respiratory droplets
• The microbial level in operating room air is directly
proportional to the number of people moving in
the room,therefore efforts should be made to
minimize personnel traffic during operarion
• Operating rooms should be maintained at positive
pressure with respect to corridor and adjacent areas.
• positive pressure prevents air flow from less clean
areas into more clean areas.
• Maintain a minimum of 15 air changes per hour, of
which at least 3 should be fresh air
• All ventilators/air conditioning systems in hospitals,
including those in operating rooms, should have two
filter beds in series, with the efficiency of the first
filter bed being >30% and that of the second filter
bed being >90%
• Air should be introduced at the ceiling and
exhausted near the floor.
• Limit the number of personnel entering the
operating room
• Laminar airflow and use of UV radiation have been
suggested as additional measures to reduce SSI risk
for certain operations.
• Laminar airflow is designed to move particle-free air
(called “ultraclean air”) over the aseptic operating
field at a uniform velocity (0.3 to 0.5
µm/sec),sweeping away particles in its path.
• Laminar airflow can bedirected vertically or
horizontally, and recirculated air is usually passed
through a high efficiency particulate air (HEPA)
filters.
• HEPA filters remove particles >0.3µm in diameter
with an efficiency of 99.97%.
• So ultraclean air and antimicrobial prophylaxis can
reduce SSI.
Environmental surfaces
• Environmental surfaces in U.S. operating rooms
(e.g., tables, floors, walls, ceilings, lights) are rarely
implicated as the sources of pathogens important
in the development of SSIs.
• Nevertheless, it is important to perform routine
cleaning of these surfaces to reestablish a clean
environment after each operation.
• Wet-vacuuming of the floor with disinfectant is
performed routinely after the last operation of the
day or night
Microbial sampling
• Because there are no standardized parameters by
which to compare microbial levels obtained from
cultures of ambient air or environmental surfaces in
the operating room, routine microbiologic sampling
cannot be justified.
• Such environmental sampling should only be
performed as part of an epidemiologic
investigation.
Conventional sterilization
• Inadequate sterilization of surgical instruments has
resulted in SSI outbreaks.
• Surgical instruments can be sterilized by steam
under pressure, dry heat, ethylene oxide, or other
approved methods.
• Microbial monitoring of steam autoclave
performance is necessary and can be accomplished
by use of a biological indicator
Flash sterilization
• It is defined as the process designated for the steam
sterilization of patient care items for immediate use.
• Flash sterilization is not recommended as a routine
sterilization method because of the lack of timely
biologic indicators to monitor performance.
Surgical attire and drapes:
• Surgical attire refers to scrub suits, caps/hoods, shoe
covers, masks, gloves, and gowns
Scrub suits:
• Surgical team members often wear a uniform called a
“scrub suit” that consists of pants and a shirt.
• if a garment(s) is penetrated by blood or other
potentially infectious materials, the garment(s) shall
be removed immediately or as soon as feasible.
• Operating Room(OR) staff are required to wear facility
approved and laundered scrubs.
• Single use jumpsuits are for use when entering the
OR for a brief period of time.
• The top of the scrub should be tucked into the pants
or fits closely to the body.
• Personal clothing must be covered by the scrubs.
• Wearing scrubs into the hospital are not to be worn in
the semi-restricted or restricted areas.
• This is to minimize cross-contamination from other
uncontrolled environments.
• Cover gowns or lab coats are required when going
outdoors and should be removed before entering
semi-restricted or restricted areas.
• Surgical attire is changed daily and whenever it
becomes visibly soiled. It should not be worn home
or taken off campus.
• All hair must be covered –including facial hair, ears,
scalp skin, and nape of neck.
• Identification should be on surgical attire, on top
scrub or jacket and is clearly visible at all times.
Masks
• The wearing of surgical masks during operations to
prevent potential microbial contamination of
incisions is a longstanding surgical tradition.
• it protects the wearer’s nose and mouth from
inadvertent exposures ([Link]) to blood and
other body fluids.
• OSHA regulations require that masks in
combination with protective eyewear, such as
goggles or glasses with solid shields, or chin length
face shields be worn whenever splashes, spray,
spatter, or droplets of blood or other potentially
infectious material may be generated and eye,
nose, or mouth contamination can be reasonably
anticipated.
• In addition, a respirator certified by the National
Institute for Occupational Safety and Health with
protection factor N95 or higher is required when
the patient has or is suspected of having infectious
tuberculosis
SURGICAL CAPS
• Surgical caps are inexpensive and reduce
contamination of the surgical field by organisms
shed from the hair and scalp.
• SSI outbreaks have occasionally been traced to
organisms isolated from the hair or scalp (S. aureus
and group A Streptococcus)
• The use of shoe covers has never been shown to
decrease SSI risk or to decrease bacteria counts on
the operating room floor.
• Shoe covers may, however, protect surgical team
members from exposure to blood and other body
fluids during an operation
GOWNS AND DRAPES
• Gowns and drapes are classified as disposable
(single use) or reusable (multiple use). Regardless
of the material used to manufacture gowns and
drapes, these items should be impermeable to
liquids and viruses.
Asepsis
• Adhere to principles of asepsis when placing
intravascular devices (e.g., central venous
catheters), spinal or epidural anaesthesia catheters,
or when dispensing and administering intravenous
drugs.
SURGICAL TECHNIQUE
• Effective hemostasis while preserving adequate blood
supply
• preventing hypothermia
• gently handling tissues
• avoiding inadvertent entries into a hollow viscus,
removing devitalized (e.g., necrotic or charred) tissues
• using drains and suture material appropriately,
eradicating dead space
• appropriately management of the postoperative
incision.
• In general, monofilament sutures appear to have the
lowest infection promoting effects.
• Drains placed through an operative incision increase
incisional SSI risk.
• Many authorities suggest placing drains through a
separate incision distant from the operative incision.
• It appears that SSI risk also decreases when closed
suction drains are used rather than open drains.
• Timing of drain removal is important as bacterial
colonization of initially sterile drain tracts increases with
the duration of time the drain is left in place
HYPOTHERMIA
• Hypothermia in surgical patients, defined as a core
body temperature below 36ºC, may result from
general anesthesia, exposure to cold.
• Mild hypothermia appears to increase incisional SSI
risk by causing vasoconstriction, decreased delivery
of oxygen to the wound space, and subsequent
impairment of function of phagocytic leukocytes
(i.e., neutrophils).
• Multiple methods can be used to maintain
normothermia like forced heating air around the
patient and warmed IV fluids.
POSTOPERATIVE
ISSUES
INCISION CARE
• . When a surgical incision is closed primarily, as most are,
the incision is usually covered with a sterile dressing for
24 to 48 hours.
• When a surgical incision is left open at the skin level for
a few days before it is closed (delayed primary closure),
it is likely to be contaminated or that the patient’s
condition prevents primary closure (e.g., edema at the
site). When such is the case, the incision is packed with a
sterile dressing.
• When a surgical incision is left open to heal by second
intention, it is also packed with sterile moist gauze and
covered with a sterile dressing.
• Wash hands before and after dressing changes and
any contact with the surgical site.
• When an incision dressing must be changed, use
sterile technique.
• Educate the patient and family regarding proper
incision care, symptoms of SSI, and the need to
report such symptoms.
DISCHARGE PLANNING
• The intent of discharge planning is to maintain
integrity of the healing incision, educate the patient
about the signs and symptoms of infection, and
advise the patient about whom to contact to report
any problems.
EVALUATION OF SURGICAL
SITE INFECTION
Fever Evaluation
• A postoperative fever is typically defined as a
temperature of 38 °C (100.4 °F) on two occasions at
least 4 hours apart, or a single temperature ≥39 °C.
• Immediate postoperative fever occurs with an
estimated incidence of 31%-50%.
• <10% of gynecologic patients who developed a
postoperative fever had an identified infectious
etiology.
• Fever was more common after abdominal hysterectomy vs other
routes and was associated with blood loss at surgery >750 mL
• The surgical wound (abdominal or vaginal) should be investigated
for signs of seroma, hematoma, cellulitis, or fascial dehiscence.
• Critical findings may include
1. Erythema beyond the immediate borders of suture or staples
2. Expressible or spontaneous drainage
3. Fluctuant masses
4. Disproportionate pain
5. Pelvic examination -localizing tenderness.
6. Rectovaginal examination -evaluation of a fluid collection or
mass in or near the cul-de-sac.
Postoperative fever workup

1. Recording a temperature every 4 hours.

2. Evaluating patients with temperature higher than
38 °C (100.4 °F) by history and physical
examination.
3. Deferring testing unless abnormal localizing signs
or symptoms are present
• 27% of patients had postoperative fever after major
gynecologic surgery, but only 11% of these febrile
patients met criteria for further testing.
• Diagnostic approach
• Physical examination:
• Induration, warmth, erythema, or frank purulent
discharge.
• Any discharge sent for microbiological culture.
• The febrile patient : appropriate fever workup
• Complete blood count (CBC), blood and urine cultures,
USG, and chest x-ray
• If an intra-abdominal abscess is suspected, a CT scan of
abdomen should be done.
• Within the initial 72 hours following surgery, blood
cultures are of low clinical utility.
• They may be considered in the setting of high fever
or persistent fever despite antibiotic administration
or if a patient meets criteria for sepsis
Imaging
• Ultrasonography may be useful in the setting of
evaluating an abdominal incision for fluid
collection, or the pelvis for fluid collection, abscess,
or hematoma.
• CT-based imaging of the abdomen or pelvis can be
helpful to diagnose abscess, ureteral, or bowel
injury as well as possible pleural fluid collections.
• CT scan may also be used to guide percutaneous
drainage.
TREATMENT OF SURGICAL
SITE INFECTION
Wound infection should be evaluated in the context of
1. Fever >4 days following an index surgery
2. Erythema and/or induration to the surgical wound.
• Initial treatment consists of opening the wound to
obtain “source control.”
• The surgeon should drain the wound and debride any
infected or necrotic material.
• Fluid from the wound cavity should be sent for Gram
stain and culture.
Empiric antibiotics should be started while waiting for
culture results if
1. Temperature is >38 °C
2. WBC count is >12 000/mm3
3. Either erythema (>5 cm) or any evidence of necrosis
is present (discoloration, presence of eschar, or
sloughing of tissue).
• Early onset of postoperative wound infection may
suggest more aggressive pathogens, such as
Streptococcus pyogenes and clostridia, which can cause
rapidly progressive necrotizing postsurgical infections
Superficial/Incisional
Infection
• Signs of superficial wound infections may include
erythema, purulent drainage, pain, or swelling.
• SSIs typically develop after the first 48 hours
postoperatively.
• Superficial SSIs may be treated with
 second- or third-generation cephalosporin (such as
cefazolin, ceftriaxone, cefoxitin) or
penicillin-β-lactamase inhibitor combination
(ampicillin-sulbactam, piperacillin-tazobactam)
Deep Incisional Surgical
Site Infections
• Fluid collections should be drained in order to
decrease the microbial burden of the source of
infection.
• In some cases, this may involve minimally invasive
drain placement or taking the patient back to the
operating room for a wound debridement and
irrigation.
• Parenteral antibiotics should typically be continued
for 24-48 hours until the patient is afebrile and
clinically improving
• RECOMMENDED EMPIRIC ANTIBIOTIC REGIMENS
FOR DEEP SURGICAL SITE INFECTIONS INVOLVING
PERINEUM, GI TRACT, OR FEMALE GENITAL TRACT
Cephalosporin plus metronidazole
 Levofloxacin plus metronidazole
 Carbapenem alone
Organ Space Infections
• Organ space SSIs may include adnexal infections or
pelvic abscess.
• Pelvic abscess formation complicates about 1% of
gynecologic surgery
• Patients with intra-abdominal infection may present
with
rapid-onset abdominal pain,
anorexia, nausea, emesis, and obstipation,
 with or without signs of inflammation, such as fever,
tachycardia, tachypnea, or tenderness.
• The principles of treatment include
 Empiric antibiotic treatment, depending on the location of the collection
and most likely source
 Culture from the organ space or abscess to narrow antimicrobial treatment
spectrum
Source control, or eliminating the infectious source, to decrease duration of
treatment and risk of persistence.
• Empiric antibiotic treatment:
Carbapenem
 Piperacillin-tazobactam
 Ceftazidime plus metronidazole
 Cefepime plus metronidazole
• Duration of antimicrobial therapy is typically 4-7 days
• Hemodynamically stable patients with peritonitis may
be initiated on empiric antibiotics and monitored
closely for up to 24 hours prior to drainage.
• Patients with a suspected interrupted viscus or fascial
dehiscence are typically best treated surgically.
• Occasionally, if adequate elimination of the infectious
source cannot be initially obtained, consideration is
given to a planned repeat exploration or deferral on
skin and/or fascial closure.
Necrotizing Infections
1. Streptococcal toxic shock,
2. Myonecrosis, and
3. Necrotizing skin infections
• Aggressive surgical management is warranted, in addition to
opening the incision, evacuating or debriding necrotic or infected
tissue with border demarcation, and initiating broad empiric
antibiotic treatment.
• Necrotizing infections are associated with a high mortality rate.
• Severe pain disproportionate to the appearance of the wound
may be the only presenting sign.
• Penicillin and clindamycin is the preferred regimen for group A
streptococcal necrotizing fasciitis
• SUGGESTED EMPIRIC BROADSPECTRUM
ANTIBIOTIC REGIMENS FOR NECROTIZING PELVIC
INFECTIONS
 Vancomycin plus piperacillin-tazobactam
 Vancomycin plus carbapenem
 Vancomycin plus ceftriaxone and metronidazole
 Linezolid plus piperacillin-tazobactam
Linezolid plus carbapenem
 Linezolid plus ceftriaxone and metronidazole
Staphylococcal wound toxic shock
syndrome
• Early findings may include fever,
hypotension, abnormal hepatic
and renal function tests, diarrhea,
and wound erythroderma.
Desquamation may be a later
finding.
• Management similarly involves
wound incision, drainage, culture
collection, and initiation of anti
staphylococcal treatment.
Vaginal Cuff Infection
• Vaginal cuff cellulitis is thought to account for 2.5%-6.25% of
SSIs following hysterectomy.
• Vaginal discharge and pelvic pain, with or without fever
• Speculum and bimanual examinations may assist in visualizing
purulent, serous, or feculent discharge, which may point the
examiner toward cuff infection, seroma, or fistulous
connection to the bowel.
• Wet mount saline microscopy and vaginal swab collection for
Gram stain and culture should be considered.
• Fluid collection or abscess within the pelvis (and no evidence
of spontaneous drainage), drainage via the vaginal cuff should
be considered.