master of surgery in general surgery
TRANSCRIPT
i
OUTCOME OF SURGICAL SITE INFECTIONS IN
ELECTIVE ABDOMINAL SURGERY WITH OR
WITHOUT SUBCUTANEOUS DRAIN
By
Dr. RAM MOHAN B.
Dissertation Submitted to Rajiv Gandhi University of Health Sciences, Karnataka, Bengaluru
In partial fulfillment of the requirements for the Degree of
MASTER OF SURGERY
IN
GENERAL SURGERY
Under the Guidance of
Dr. SHARAD M. TANGA M.S. Gen. Surgery
Professor
DEPARTMENT OF SURGERY MAHADEVAPPA RAMPURE MEDICAL COLLEGE,
KALABURAGI, KARNATAKA
2017
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Rajiv Gandhi University of Health Sciences,
Bengaluru, Karnataka.
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation/thesis entitled
““““OUTCOME OF SURGICAL SITE INFECTIONS IN ELECTIVE
ABDOMINAL SURGERY WITH OR WITHOUT
SUBCUTANEOUS DRAIN”””” is a bonafide and genuine research work
carried out by me under the guidance of Dr. SHARAD M. TANGA
Professor, Department of General Surgery, M.R. Medical College,
Kalaburagi.
iii
Rajiv Gandhi University of Health Sciences,
Bengaluru, Karnataka.
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation ““““OUTCOME OF
SURGICAL SITE INFECTIONS IN ELECTIVE ABDOMINAL
SURGERY WITH OR WITHOUT SUBCUTANEOUS DRAIN”””” is
a bonafide research work done under my guidance by
Dr. Ram Mohan B in partial fulfillment of the requirement for degree of
M.S. in General Surgery.
iv
Rajiv Gandhi University of Health Sciences,
Bengaluru, Karnataka.
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE INSTITUTION
This is to certify that the dissertation entitled
““““OUTCOME OF SURGICAL SITE INFECTIONS IN ELECTIVE
ABDOMINAL SURGERY WITH OR WITHOUT
SUBCUTANEOUS DRAIN”””” is a bonafide research work
done by Dr. RAM MOHAN B under the guidance of
Dr. SHARAD M. TANGA, Professor, Department of General Surgery,
M.R. Medical College, Kalaburagi.
xi
LIST OF TABLES
TABLE No.
TABLE PAGE No.
1. PATHOGENS COMMONLY ASSOCIATED WITH WOUND INFECTIONS AND FREQUENCY OF OCCURENCE.
11
2. PATHOGENS ISOLATED FROM POST-OPERATIVE SURGICAL SITE INFECTION AT UNIVERSITY HOSPITAL.
12
3. AMERICAN SOCIETY OF ANAESTHESIOLOGISTS(ASA) CLASSIFICATION OF PHYSICAL STATUS.
21
4. PREDICTIVE PERCENTAGE OF SSI OCCURRENCE BY WOUND TYPE AND RISK INDEX.
22
5. SURGICAL WOUND CLASSIFCATION AND SUBSEQUENT RISK OF INFECTION (If no antibiotics used).
23
6. RECOMMENDATIONS FOR PROPHYLACTIC ANTIBIOTICS AS INDICATED BY PROPHYLACTIC INFECTIVE MICROORGANISM INVOVLED.
27
7. GENDER DISTRIBUTION. 37
8. CO-MORBID CONDITION 38
9. INDICATION FOR SURGERY 39
10. TYPE OF ANAESTHESIA 40
11. SURGERY DONE 41
12. PLACEMENT OF DRAIN 42
13. SIGNS OF INFECTION 43
14. CULTURE AND SENSITIVITY 44
15. OVERALL RATE OF SURGICAL SITE INFECTION 45
16. TYPE OF SURGERY AND RESULTS 46
17. CO-MORID CONDITION AND RESULTS 46
18. DRAIN AND RESULTS 46
19. SIGNS OF INFECTION AND RESULTS 47
20. SIGNS OF INFECTION AND DRAIN 47
xii
LIST OF FIGURES
Figure No Figures
Page No.
1. GENDER DISTRIBUTION 37
2. CO-MORBID CONDITION 38
3. TYPE OF SURGERY 41
4. PLACEMENT OF DRAIN 42
5. SIGNS OF INFECTION 43
6. CULTURE AND SENSITIVITY 44
7. RESULTS 45
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ABSTRACT
INTRODUCTION:
Surgical site infections are among the most common complication of in-patient admission and have a serious consequence in terms of outcome and cost. In spite of use of antiseptics, strict aseptic precautions during surgery and use of broad spectrum antibiotics, surgical site infections occur in day to day practice. Wound collection and the consequent sequelae results in prolonged hospital stay, continued use of antibiotics and resultant cost. This study aims to evaluate the outcome of such infection with and without the use of gauze piece drain kept subcutaneously.
MATERIALS AND METHODS:
This is a prospective study which was conducted at the hospital attached to M. R. MEDCICAL COLLEGE, KALBURGI from November 2015 to MAY 2017. A total of 150 patients who underwent elective abdominal surgeries for various conditions were included in the study. Patients were divided equally into two groups in which drain was kept in 75 patients and drain was not kept in 75. The aim of the study was to evaluate the outcome of surgical site infection in elective abdominal surgeries with and without gauge piece as subcutaneous drain. All the patients above the age of 15 years who underwent elective abdominal surgeries for various causes were included in the study. Intraperitoneal suction drains were used wherever necessary and a gauge piece was kept as a drain in the subcutaneous plane before closing skin in half of the patients who underwent surgery. Post operatively antibiotics were administered and adequate analgesia was provided. The subcutaneous drain was removed 48 hours after surgery and the wound was inspected for any evidence of infection starting from third post operative day till the patient was discharged. Discharge from the wound if found was sent for culture and sensitivity and the antibiotics were changed accordingly. Patients were studied only for superficial incisional surgical site infections and the outcome of surgical site infection in those with drain and without drain.
RESULTS:
Overall:
• The mean age of males and females in the study were 30.49+/-15.0 1 years and 25.82+/-13.9 years respectively.
• Patients were equally divided in both the groups 75 patients with drain and 75 patients without drain.
• Very few had signs of infection. • 20 (13.36%) cases were infected when compared to 130 (86.66%) uninfected
cases. • Most commonly isolated organism was E.coli.
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In patients with drain and without drain:
• Patients with drain had 6.0% infection , those without drain had 7.3% infection.
• Of the surgeries patients underwent appendicectomy had 8.6% infection while cholecystectomy had 4.6% infection.
• Patients who underwent surgery with co-morbid conditions along with required surgery had 3.76 times more chances of infection than patients who donot had co- morbid conditions.
• Patients with drain had 1.3% less infection than patient without drain. • Patients with signs of infection had 179.11 times infection rate than those
who didn’t had any signs of infection.
CONCLUSION: The overall incidence of surgical site Infection was found to be 13.36%. With higher incidence among females compared to males. The most common isolated organism being Ecoli. Those with drain 1.3% less incidence of getting infected than those without drain indicating that subcutaneous drain reduces the chances of infection there by reducing morbidity, cost and duration of hospital stay.
1
INTRODUCTION
Surgical Site Infections (SSI) are the most common nosocomial Infections and
a major cause of postoperative morbidity and resource utilization .1, 2 An infected
wound can prolong hospitalization by 5 to 20 days and subsequently increase medical
costs. 3
Currently, in the United States alone, an estimated 27 million surgical
procedures are performed each year. 4The National Nosocomial Infection Surveillance
System (NNIS) established in 1970, monitors reported trends in nosocomial infections
in the US acute care hospitals. Based on these reports, Surgical Site Infections (SSI’s)
are the most frequently reported nosocomial infections accounting for 14% to 16% of
all nosocomial infections among hospitalized patients.5
The recent English Nosocomial Infection National Surveillance Scheme
(NINSS) reported that the overall incidence of SSI’s was 4.3% of all surgical
operations, of which 25% were serious deep or organ/ space infections.6
In order to accurately assess success in infection prophylaxis, a standard
“acceptable” wound infection rate must be established at each institution.
Numerous studies on surgical wound infections have appeared in the literature
and perhaps the most thorough and comprehensive study was one between five
University centers in which 14,854 patients had 15,613 operative wounds as reported
in Annals of surgery 40 years ago.8
The efforts of Geubbels and colleagues point out the difficulties with which all
countries struggle in monitoring Surgical Site Infection rates .9 With the above in
mind, the identification of SSI’s involves interpretation of clinical and laboratory
2
findings, and it is crucial that a surveillance programme uses definitions that are
consistent and standardized; otherwise inaccurate or uninterpretable SSI rates will be
computed and reported. 10
General surgery has seen dramatic changes over the past 30 years. It has
evolved from open procedures with few drug treatments to a specialty that has
enthusiastically embraced minimal invasive techniques and new drug treatments.
The growing attention and advancements in the field of hospital infection
prevention has mainly taken place in countries with adequate resources. Many
countries with few resources have ineffective hospital infection prevention
programmes, if any at all. While the SSI rates have decreased in countries with more
resources, the relatively few studies conducted in countries with more limited health
budgets identified higher rates.11 Extending nosocomial infection surveillance and
prevention efforts to countries that presently lack effective programme is therefore
viewed as a challenge for the future.
Surveillance of SSI with feedback of appropriate data to surgeons has been
shown to be an important component of strategies to reduce SSI risk. To create an
effective hospital infection programme, information about local patterns is essential.
This type of data is useful for both individual hospitals and national health care
planners in setting programme priorities, monitoring effects of different preventive
actions and in setting goals for their infection control efforts.
3
AIM OF THE STUDY
To evaluate the outcome of surgical site infection in elective abdominal
surgery with and without gauge piece kept as drain subcutaneously.
4
REVIEW OF LITERATURE
Historical Aspects
The ancient Egyptians were the first civilization to have trained physicians to
treat physical ailments. Medical papyri, such as the Edwin Smith papyrus (circa 1600
BC) and the Ebers papyrus (circa 1534 BC), provided detailed information of
management of disease, including wound management with the application of various
potions and grease to assist healing”.12,13
Hippocrates (Greek physician and surgeon, 460-377 BC), known as the father
of medicine, used vinegar to irrigate open wounds and wrapped dressings around
wounds to prevent further injury. His teachings remained unchallenged for centuries.
Galen (Roman gladiatorial surgeon, 130-200 AD) was first to recognize that pus from
wounds inflicted by the gladiators heralded healing (pus bonum et laudabile [“good
and commendable pus”]). Unfortunately, this observation was misinterpreted, and the
concept of pus preempting wound healing persevered well into the eighteenth century.
The link between pus formation and healing was emphasized so strongly that foreign
material was introduced into wounds to promote pus formation-suppuration. The
concept of wound healing remained a mystery, as highlighted by the famous saying
by Ambroise Pare (French military surgeon, 1510-1590), “I dressed the wound. God
healed it”.14
The scale of wound infections was most evident in times of war. During the
American Civil War, erysipelas (necrotizing infection of soft tissue) and tetanus
accounted for over 17,000 deaths (anonymous, 1883). Because compound fractures at
5
the time almost invariably were associated with infection, amputation was the only
option despite a 25-90% risk of amputation stump infection.
Robert Koch (Professor of Hygiene and Microbiology, Berlin, 1843-1910)
first recognized the cause of infective foci as secondary to microbial growth in his
nineteenth century postulates. Semmelweis (Austrian obstetrician, 1818-1865)
demonstrated a 5-fold reduction in puerperal sepsis by hand washing between
performing postmortem examinations and entering the delivery room. Joseph Lister
(Professor of Surgery, London, 1827-1912) and Louis Pasteur (French bacteriologist,
1822-1895) revolutionized the entire concept of wound infection. Lister recognized
that antisepsis could prevent infection (Lister, 1867). He placed carbolic acid into
open fractures to sterilize the wound and prevent sepsis and hence the need for
amputation. In 1871, Lister began to use carbolic spray in the operating room to
reduce contamination. However, the concept of wound suppuration persevered even
among eminent surgeons, such as John Hunter, 1728-1793.
World War I (WWI) resulted in new types of wounds from high-velocity
bullet and shrapnel injuries coupled with contamination by the mud from the trenches.
Antoine Depage (Belgian military surgeon, 1862-1925) reintroduced wound
debridement and delayed wound closure and relied on microbiological assessment of
wound brushings as guidance for the timing of secondary wound closure.17 Alexander
Fleming (microbiologist, London, 1881-1955) performed many of his bacteriological
studies during WWI and is credited with the discovery of penicillin.
As late as the nineteenth century, aseptic surgery was not routine practice.
Sterilization of instruments began in the 1880s as did the wearing of gowns, masks,
and gloves. Halsted (Professor of Surgery, Johns Hopkins University, United States,
6
1852- 1922) introduced rubber gloves to his scrub nurse (and future wife) because she
was developing skin irritation from the chemicals used to disinfect instruments. The
routine use of gloves was introduced by Halsted’s student J. Bloodgood.
Penicillin first was used clinically in 1940 by Howard Florey. With the use of
antibiotics, a new era in the management of wound infections commenced.
Unfortunately, eradication of the infective plague affecting surgical wounds has not
ended because of the insurgence of antibiotic-resistant bacterial strains and the nature
of more adventurous surgical intervention in immunocompromised patients and in
implant surgery.
Magnitude of the Problem
Surgical site infections (SSI) are not an extinct entity and account for 14-16%
of the estimated 2 million nosocomial infections affecting hospitalized patients in the
United States.18 Martone W et al;19 showed SSI accounting for an average of 7.3
excess hospital days and more than 1.6 million dollars of extra hospital charges.
Internationally, the frequency of SSI is difficult to monitor because criteria for
diagnosis might not be standardized. A survey sponsored by the World Health
Organization demonstrated a prevalence of nosocomial infections varying from 3-
21%, with wound infections accounting for 5-34% of the total.20
Collected data on the incidence of wound infections probably underestimate
true incidence because most wound infections occur when the patient is discharged,
and these infections may be treated in the community without hospital notification.
7
Mortality/Morbidity:
SSIs are associated not only with increased morbidity but also with mortality.
Seventy-seven percent of the deaths of surgical patients were related to surgical
wound infection.21 Kirkland et al (1999)22 calculated a relative risk of death of 2.2
attributable to SSIs, compared to matched surgical patients without infection.
Definition of SSI
SSI is a difficult term to define accurately because it has a wide spectrum of
possible clinical features. The Center for Disease Control and Prevention (CDC) have
defined SSI to standardize data collection for the National Nosocomial Infections
Surveillance (NNIS) program (CDC, 1996).23,24 SSIs are classified into incisional
SSIs, which can be superficial or deep, or organ/space SSIs, which affect the rest of
the body other than the body wall layers.
Superficial incisional SSI: Infection involves only the skin and subcutaneous
tissues of the incision.
Deep incisional SSI: Infection involves deeper tissues, such as fascial and
muscle layers. This also includes infection involving both superficial and deep
incision sites and organ/space SSI draining through incision.
Organ/space SSI: Infection involves any part of the anatomy in organs and
spaces other than the incision, which was opened or manipulated during operation.
8
Diagnostic Criteria21,26:
According to a report by the NNIS programme,14 surgical site infections are
defined as follows:
Superficial incisional SSI Criteria
Infection occurs at incision site within 30 days after surgery.
Infection involves only skin and subcutaneous tissue of the incision.
At least one of the following:
o Purulent drainage from the superficial incision.
o Organism isolated from culture of fluid or tissue from the superficial
incision.
o Surgeon deliberately opens wound and there is at least one sign or
symptom (pain, tenderness, localized swelling, redness or heat) unless
the wound culture is negative.
o Diagnosis of infection by a surgeon or attending physician.
Deep incisional SSI Criteria:
Infection occurs at the operative site.
o within 30 days after surgery if no implant (non human derived foreign
body that is permanently placed in the patient during surgery) is left in
place.
o within one year after surgery if an implant is left in place.
Infection appears related to surgery.
Infection involves deep soft tissue (muscle and facial layers).
At least one of the following:
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o Purulent drainage from the deep incision but not from the organ/space
component of the surgical site.
o Wound dehiscences or is deliberately opened by the surgeon when patient has
fever (>380C) and/or localized pain and or tenderness unless the wound
culture is negative.
o An abscess or other evidence of infection involving the deep incision seen on
direct examination or by radiological examination.
o Diagnosis of deep incisional surgical site infection by surgeon or attending
physician.
Organ/Space SSI Criteria:
• Infection occurs
o within 30 days after surgery if no implant (non human derived foreign body
that is permanently placed in the patient during surgery) is left in place.
o within one year after surgery if an implant is left in place.
• Infection appears related to surgery.
• Infection involves any part of anatomy other than the incision opened or
manipulated during an operative procedure.
• At least one of the following:
o Purulent drainage from a drain that is placed through a stab wound into the
organ/space.
o Organisms isolated from an aseptically obtained culture of fluid or tissue in
the organ / space.
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o An abscess or other evidence of infection involving the organ space seen on
direct examination during surgery, by histopathological examination or by
radiological examination.
o Diagnosis of an organ/space surgical site infection by surgeon or attending
physician.
MICROBIOLOGY
The establishment of a wound infection requires a microbial inoculum of the
surgical site in a susceptible host. Factors affecting wound infection include
preoperative removal of hair, especially with instruments capable of causing skin
abrasion, inadequate skin preparation with bactericidal solution, host who is
immunocompromised, and delayed prophylaxis with antibiotics or incorrect choice of
antibiotics.
The traditional microbial concentration quoted as being highly associated with
SSIs is that of bacterial counts higher than 10,000 organisms per gram of tissue and in
the case of burns, organisms per cm2 of wound (Krizek, 1975).16 The infective process
not only depends on the number of contaminating microbes but also on their virulence
and whether the resistance offered by the host is strong enough to fight off the
invading organisms.
Most SSIs are contaminated by the patient’s own endogenous flora, which are
present on the skin, mucous membranes, or hollow viscera. The usual pathogens on
skin and mucosal surfaces are gram-positive cocci (notably staphylococci); however,
gram negative aerobes and anaerobic bacteria contaminate skin in the groin/perineal
areas. The contaminating pathogens in gastrointestinal surgery are the multitude of
11
intrinsic bowel flora, which include Gram-negative bacilli (eg, Escherichia coli) and
Gram-positive microbes, including enterococci and anaerobic organisms. The
pathogens and their frequency of occurence are listed below (Table — 1 & 2). Gram-
positive organisms, particularly staphylococci and streptococci, account for the vast
majority of exogenous flora involved in SSIs. Sources of such pathogens include
surgical/hospital personnel and intraoperative environment, including surgical
instruments, articles brought into the operative field, and the operating room air.
Table no. 1
Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence20
Pathogen Frequency (%)
1990-96 1986-89
Staphylococcus aureus 20 17
Coagulase-negative staphylococcus
14 12
Enterococcus 12 12
Escherichia coli 8 10
Pseudomonas aeruginosa 8 8
Enterobacter species 7 8
Proteus mirabilis 3 4
Klebsiella pneumoniae 3 3
Other Streptococci 3 3
Candida Albicans 3 2
Group D Streptococci 2 -
Other gram-positive aerobes
2 -
Bacteroides fragilis 2 -
Staphylococcus aureus 20 17
12
Table No.2
Pathogens Isolated from Post-operative Surgical Site Infection at University
Hospital26,28
Pathogen % of Isolates
Staphylococcus (coagulase negative) 25.6
Enterococcus (Group D) 11.5
Staphylococcus aureus 8.7
Candida albicans 6.5
Escherichia coli 6.3
Pseudomonas aeruginosa 6.0
Corynebacterium 4.0
Candida (non-albicans) 3.4
Candida (non-albicans) V 3.4
a-hemolytic Streptococcus 3.0
Klebsiella pneumonia 2.8
Vancomycin resistant enterococcus 2.4
Enterobacter cloacae 2.2
Citrobacter species 2.0
RISK FACTORS OTHER THAN MICROBIOLOGY
Various factors that may influence the risk of surgical site infection may be
broadly classified as
PATIENT FACTORS
1. Age: Extremes of age is associated with increased incidence of wound
infection, perhaps owing to decreased immunocompetence. However it
appears to be a modest risk factor. Clinical data to support this finding is
lacking
13
2. Nutritional status: Important aspects appears to be in relation to protein
malnutrition. Malnutrition appears to be a quite common finding in surgical
patients. It is also shown that host resistance decreases with loss of body
weight in malnutrition. Habte Gabre et a1;29 showed malnutrition is
predisposing factor for SSI. Though a definite risk of sepsis is associated with
malnutrition, it can not be solely responsible for wound infection
3. Diabetes: Although the pathophysiology of impaired wound healing in
diabetes is not completely understood, several studies seem to indicate that it
is a significant risk factor for wound infection. In the original 5 years study by
Cruse and Foord30 the clean wound infection rate was 10.7% in diabetics
compared to an overall clean wound infection rate of 1.8%. Dronge AS et al;31
showed incidence of infection more in diabetic patients.
4. Smoking: The effect of smoking on wound infection rates has not been
studied well. Although data is sparse, the concept of smoking as a risk for
wound infection should be heeded because it is a potentially alterable behavior
in the pre operative period. Nagachinta et a1;32 found a slightly higher
infection rate among smokers who underwent cardiac surgery.
5. Obesity: It has not been consistently found to be related to wound infections.
Cruse and Foord30 found a 13.5% wound infection rate in obese individuals in
their initial report of 18,090 patients from the Foothills Hospital Study, but it
is not clear whether this effect was independent of other diseases also
associated with wound infections. It may be only weakly associated with
wound infections. Nystrom Po et a1;33 showed that SSI increases with obesity,
one reason being a decrease in blood circulation in fat tissue.
14
6. Co-Existent infection at remote body site: In a study conducted by Garibaldi
et al;34 on 1852 patients, the presence of distant infection was associated with
an overall infection rate of 16% as compared to 6.1% in the patients without
distant infection. However on multiple regression analysis, this association
was no longer valid. It is unclear whether pre-operative treatment of distal
infection reduced the subsequent risk to the wound. It seems prudent to
continue to consider remote site infection a risk factor and to treat it
appropriately prior to operation.
7. Altered immune response: Alteration in immune status has been considered
to be a risk factor for wound infection. However, several studies have failed to
show an independent correlation between the two.
8. Length of the pre-operative stay: It is commonly held that duration of
preoperative hospitalization is associated with wound infection, theoretically
via colonization with multiple resistant organisms. A 5 year study by Cruse
and Foord30 appear to support this. However, stepwise regression analysis
revealed this factor not to be an independent predictor. The association must
be thus considered unproven.
OPERATIVE FACTORS
1. Duration of the Surgical scrub: Hand washing with soap and an antiseptic
agent removes dirt and desquamated skin and reduces the number of microbes
on the skin. Although tradition calls for scrubbing for 10 minutes and using
two brushes, washing for 5 minutes and using one brush accomplishes equal
reduction in skin bacterial counts.
15
2. Pre-operative shaving: Pre-operative shaving done night before operation,
provides ample time for the bacterial proliferation in any nicks and cuts, with
higher rates of infection, as compared to when it is done immediately before
the operation. Use of hair clippers can further reduce infection rates.
3. Pre-operative skin preparation: Disinfecting the operative site usually
entails washing the site with a germicidal soap solution for 5-10 minutes
followed by painting the site with antimicrobial solution such as chlorhexidine
or povidone iodine. Painting the site with alcohol solution of povidone-iodine,
which can be accomplish in less than 1 minute, is as effective as a 5 minutes
scrub with povidone iodine followed by painting with povidone iodine
solution.
4. Operative room ventilation: Filtration of air can reduce the number of dust
particles to which microbes can adsorb. Operative room air should have
positive pressure relative to air in the corridors so that unfiltered air does not
enter the operating room. Special laminar flow system can further reduce the
likelihood of air borne infection.
5. Antimicrobial prophylaxis: If antibiotics are given to prevent infection after
surgery or instrumentation, they should be used when local wound defences
are not established (the decisive period). Ideally, maximal blood and tissue
levels should be present at the time at which the first incision is made and
before contamination occurs. Intravenous administration at induction of
anaesthesia is optimal. In long operations or when there is excessive blood
loss or when unexpected contamination occurs, antibiotics may be repeated at
4-hourly intervals during surgery, as tissue antibiotics levels often fall faster
than serum levels. There is no evidence that further doses of antibiotics after
16
surgery are of any value in prophylaxis against infection and the practice can
only encourage the development of antibiotic resistance. The choice of an anti-
biotic depends on expected spectrum of organism likely to be encountered, the
cost and local hospital policies, which are based on experience of local
resistance trends. The use of newer, broad spectrum antibiotics for prophylaxis
should be avoided. Table no. 6 gives examples of antibiotics that can be used
in elective surgical operations. Patients with known valvular heart disease or
with any implanted vascular or orthopedic prosthesis should have prophylactic
antibiotics during dental, urological or open viscus surgery. Single doses of
broad- spectrum penicillin, for example amoxicillin, orally or intravenously
administered, are sufficient for dental surgery. In urological instrumentation, a
single dose of gentamycin is often used.
6. Surgical technique: The various factors like poor tissue handling, poor
haemostasis, failure to obliterate dead space, tissue trauma contribute to
increased incidence of wound infection.
7. Duration of the operation: Risk of infection has been shown to be
proportional to the length of the operative procedure. Cruse and Foord19
showed increased wound infections with longer procedures, roughly doubling
with every hour of the procedure. Garibaldi et al;34 revealed an operative
duration of greater than 2 hours to be associated with increased wound
infections. It is a significant risk factor for wound infection.
8. DRAIN: Drains are inserted to allow fluid or air that might collect at an
operation site or in a wound to drain freely to the surface. The fluid to be
drained may include blood, serum, pus, urine, faeces, bile or lymph. Drains
may also allow wound irrigation in certain specific circumstances. The
17
adequate drainage of fluid collections prevents the development of cavities or
spaces that may delay wound healing. Their use can be regarded as
prophylactic in elective surgery and therapeutic in emergency surgery. Three
basic principles apply in the use of drains:
1. Open drains that utilize the principle of gravity.
2. Semi-open drains that works on the principle of capillary effect.
3. Closed drains systems that utilize suction.
They may be placed through the wound or through a separate incision,
although it has been clearly shown that placing them through the wound leads
to an increased risk of wound infection. With regard to indication for
drainage, in the past drains were in common use ever since Lawson Tait in
1887 suggested ‘when in doubt drain!’ However, this edict has come under
strong criticism recently and the value and use of drains has been the subject
of close scrutiny, and their use still remains controversial.
Protagonists suggest that the use of drains may:
Remove any intraperitoneal or wound collection of ascities, serum,
bile, chyle, pancreatic or intestinal secretion:
Act as an signal for any post operative hemorrhage or anastomotic
leakage;
Provide a tract for later drainage.
However, the antagonists claim that the presence of a drain may:
Increase intra-abdominal and wound infection;
Increase anastomotic insufficiency;
Increase abdominal pain;
18
Increase hospital stay;
Decrease pulmonary function.
In realty, the use of drains currently tends to depend on a surgeon’s
individual preference. The randomized controlled trails suggesting that their use in
gastric, duodenal, small bowel, appendix and biliary surgery is unnecessary, and may
cause more problems than benefits, and this is now reflected in current practice. There
are also randomized controlled trails to suggest that they are also not required in
colorectal, liver and pancreatic surgery and yet in today’s practice the majority of
surgeons will still utilize these drains in these forms of surgery. The only area of
alimentary tract surgery where drains are still routinely advocated is for oesophageal
surgery, although here the evidence is low .
SPECIALIST USE OF DRAINS
There are certain clinical situations where specialist forms of drainage are
required.
Chest drains
These are indicated for pneumothorax, pleural effusion, hemothorax or to
prevent the collection of fluid or air after thoracotomy. Once the drain has been
inserted, it should be connected to an underwater sealed drain. This system allows air
to leave the pleural cavity, but cannot draw it back in with the negative pressure that
is created in the intrathoracic cavity. During the respiratory process, it should be
checked that the meniscus of the fluid is swinging to ensure that the tube is not
blocked. Suction can be applied to the venting tube at the bottle whenever there is
significant drainage of fluid or air expected. Between 10 and 20 mm of mercury are
adequate to obtain a gentle flow of bubbles from the chest cavity.
19
T-tube drains
After exploration of the common bile duct, a T-tube may be inserted into the
duct which allow the bile to drain while the sphincter of oddi is in spasm
postoperatively. Once the sphincter relaxes, bile drains normally down the bile duct
and to the duodenum. To assist choleresis, it is often advisable to convert the lumen
of the limb of the T into a gutter, which also facilitates removal.
Guided drainage
For many intra-abdominal collections or abscess, drains may be inserted under
ultrasound or computed tomography (CT) control. In order for such drains to remain
in site, the drain is often fashioned with a pigtail to discourage inadvertent removal.
Subcutaneous drain
These drains are placed subcutaneously before closing skin incision to
obliterate the subcutaneous dead space and drain collection that is known to occur in
the immediate post operative period. Tube drains, Gauze piece are used to drain
subcutaneous collections. These drains are kept in place for 48 hours and removed
there after.
Removal drains
A drain should be removed as soon as it is no longer required, as if left in, it
can itself predispose to fluid collections as a result of tissue reaction. Indeed there is
evidence that by 7 days only 20 percent of drains are still functioning. It should be
stressed how it is to define the objective of each individual drain and to ensure that
once that objective has been met, the drain is removed. If a drain is used at all, the
following principles may apply:
20
Drains put in to cover perioperative bleeding may usually be removed after 24
hours, e.g. thyroidectomy.
Drain put in to drain serous collections usually can be removed after 5 days,
e.g. mastectomy.
Drains put in because of infection should be left until the infection is subsiding
or the drainage is minimal.
Drain put in to cover colorectal anastomosis should be removed at about 5-7
days. However, it should be stressed that in no way does a drain prevent any
intestinal leakage, but merely may assist any such leakage to drain externally
rather than to produce life threatening peritonitis.
Common bile duct T-tubes should remain in for 10 days. However, once the
T-tube cholangiogram has shown that there is free flow of bile into the
duodenum and that there are no retained stones, some surgeons like to clamp
the T-tube prior to removal. The 10-day period is required to minimize the risk
of biliary peritonitis after removal.
Any suction drain should have the suction taken off prior to removal of drain.
During the removal of chest tube drain, the patient should be asked to breathe
in and hold his breath, thus doing a valsalva manoeuvre. In this way, no air is
sucked into the pleural cavity as the tube is removed. Once the drain is out, a
previously inserted purse string suture should be tied.
RISK ASSESSMENT
The current risk index used to predict the risk of developing a wound infection
is the NNIS system of the CDC (1996).23 The risk index category is established by the
added total of the risk factors present at the time of surgery. For each risk factor
21
present, a point is allocated; risk index values range from 0-3. This risk index is a
better predictor for SSIs than the surgical wound classification.36
The elements that constitute the NNIS risk index are as follows
Pre-operative patient physical status assessed by the anesthesiologist and
classified by the American Society of Anesthesiologist as greater than 3
(ASA>3).
Operative status as either contaminated or dirty.
Operation lasting longer than T hours, when T is the 75th percentile of the
specific operation performed.
TABLE NO.3
American Society of Anesthesiologists (ASA) classification of physical status37
ASA.Score Characteristics
1 Normal healthy patient.
2 Patient with mild systemic disease.
3 Patient with severe systemic disease that limits activity but is not incapacitating
4 Patient with an incapacitating systemic disease that is a constant threat to life.
5 Moribund patient not expected to survive 24 hours with or without operation.
Predictive percentage of SSI occurrence by wound type and risk index.36
Using the NNIS risk index it could be predicted preoperatively, the possibility
of the wound to get infected, which can be used as a guideline for the use of
prophylactic antibiotics for a patient undergoing a surgical procedure. The following
table gives the predictive percentage of SSI based on NNIS risk grading:
TABLE NO.4
Predictive percentage of SSI occurrence by wound type and risk index
22
At Risk Index Predictive % of SSI
0 1.5
1 2.9
2 6.8
3 13.0
23
CLASSIFICATION OF SURGICAL WOUNDS
A set of definitions was put forth in 1964 by the National Research Council,
Ad Hoc Committee on trauma, to help predict the probability of wound infection,
based on intra operative bacterial contamination. These definitions have repeatedly
been shown to have a strong association with wound infections. The surgical wounds
have been divided into four categories as shown in the table below.
TABLE NO. 5
Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used)*26,38
Clean (Class I) Uninfected operative wound.
No acute inflammation. Closed primarily. Respiratory, gastrointestinal, biliary, and urinary tracts not entered. No break in aseptic technique. Closed drainage used if necessary.
<2
Clean-contaminated (Class II)
Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage. No evidence of infection or major break in aseptic technique. Example: appendectomy
<10
Contaminated (Class III) Nonpurulent inflammation present. Gross spillage from gastrointestinal tract. Penetrating traumatic wounds <4 hours. Major break in aseptic technique.
About 20
Dirty-infected (Class IV)
Purulent inflammation present Preoperative perforation of viscera Penetrating traumatic wounds >4 hours
About 40
24
INVESTIGATIONS
LAB STUDIES
Collection of specimen: Pus or exudate is often submitted on a swab for Lab
investigation. The swab tends to dessicate the specimen and trap the bacteria, which
are then not released on culture plate. Whenever possible, pus or exudates should be
submitted in a small screw capped bottle, a firmly stoppered tube or syringe, or a
sealed capillary tube. When swab is used, two swabs should be taken, one for the
preparation of smear for microscopy and the other for seeding culture.
STAINING METHODS:
The simplest and usually the quickest method involves obtaining a Gram stain
for infective organisms. Based on whether they retain the primary crystal violet dye,
the bacteria are classified as Gram positive or negative. Gram positive bacteria appear
deep blue or purple as they retain the primary stain. Gram negative bacteria loose the
primary stain and take up the counterstain safranin and appear red or pink. The
staining spectrum includes almost all bacteria, many fungi, parasites and
miscellaneous protozoan cysts. Gram stain can also be utilized to differentiate
epithelial and inflammatory cells.
CULTURE TECHNIQUES:
Most laboratories routinely will culture for both aerobic and anaerobic
organisms. A combination of enriched, non selective, selective and differentiated
media is used for the isolation of both aerobic and anaerobic bacterias from clinical
specimen. Isolation of single colonies allows further subcultures and identification of
specific organisms. Sensitivity testing then follows, mainly for aerobic organisms.
25
IMAGING STUDIES:
Ultrasound can be used to scan the infected wound area to assess whether any
collection needs drainage.
PREVENTION OF SSI:
The use of antibiotics was a milestone in the effort to prevent wound infection.
The concept of prophylactic antibiotics was established in the l960s when
experimental data established that antibiotics had to be in the circulatory system at a
high enough dose at the time of incision to be effective.39
General agreement exist that prophylactic antibiotics are indicated for clean
contaminated and contaminated wounds. Antibiotics for dirty wounds are part of the
treatment because infection is established already. Clean procedures might be an issue
of debate. No doubt exist regarding the use of prophylactic antibiotics in clean
procedure in which prosthetic devices are inserted because infection in these cases
would be disastrous for the patient. However, other clean procedure (Eg. breast
surgery) may be a matter of contention. 40,41
Qualities of prophylactic antibiotics include efficacy against predicted
bacterial microorganisms most likely to cause infection, good tissue penetration to
reach wound involved, cost effectiveness and minimal disturbance to intrinsic body
flora (eg. Gut).
The timing of administration is critically important because the concentration
of the antibiotic should be at therapeutic levels at the time of incision during surgical
procedure, and ideally, for few hours post operatively (CDC1996). Administration of
the antibiotic intravenously, 30 minutes prior to incision is recommended.41
26
Antibiotics should not be administered more than 2 hours prior to surgery. Colorectal
surgical prophylaxis additionally require bowel clearance with enemas and oral non
absorbable antimicrobial agent one hour before surgery. High risk cesarean surgical
cases require antibiotic administration as soon as the clamping of the umbilical cord is
completed (CDC-1996).
RECOMMENDATIONS FOR PROPHYLACTIC ANTIBIOTICS AS
INDICATED BY PROBABLE INFECTIVE MICRO ORGANISM
INVOLVED42
Studies indicate that prophylactic use of antibiotic can help to control the
incidence of SSI. Prophylaxis should be directed against the bacteria likely to
contaminate the wound. For clean operations, Staphylococcus aureus, Staphylococcus
epidermidis and Gram negative bacteria are the most likely cause of wound infection.
Gram negative enteric bacteria are the most likely causes of wound infection
following gastroduodenal and biliary tract procedure, colorectal surgery,
appendicectomy and gynecological surgery. Antibiotics should be administered 30-60
minutes prior to the incision. The dose of the antibiotic should be repeated if the
operation lasts longer than 4 hours or twice the half life of antibiotic used. It should
not be continued beyond the day of surgery. Current guidelines for surgical wound
prophylaxis as proposed by Woods R K42 are given in the table below.
27
TABLE NO. 6
Recommendations for Prophylactic Antibiotics as Indicated by Probable
Infective Microorganism involved
Operation Expected Pathogens Recommended Antibiotic Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic procedures
S aureus, coagulase-negative staphylococci
Cefazolin 1-2 g
Appendectomy, biliary procedures
Gram-negative bacilli and anaerobes
Cefazolin 1-2 g
Colorectal surgery Gram-negative bacilli and Anaerobes
Cefotetan 1-2 g or cefoxitin 1-2 g plus oral neomycin I g and oral erythromycin 1 g (start 19 h preoperatively for 3 doses)
Gastroduodeal surgery Gram-negative bacilli and streptococci
Cefazolin 1-2 g
Vascular surgery S aureus, Staphylococcus epidermidis, gram-negative bacilli
Cefazolin 1-2 g
Head and neck surgery S aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approach
Cefazolin 1-2 g
Obstetric and gynecological procedures
Gram-negative bacilli, enterococci, anaerobes, group B streptococci
Cefazolin 1-2 g
Urology procedures Gram-negative bacilli Cefazolin 1-2 g
28
RECOMMENDATIONS (PARTIAL) FOR THE PREVENTION OF SSIs, APRIL 1999, (NON DRUG BASE)21
Patient preparation
Identify and treat all infections remote from the surgical site. Delay operation
in elective cases until infection is treated.
Do not remove hair unless it infringes on the surgical field. If hair removal is
required, it should be removed immediately before operation and preferably
with electric clippers.
Patients should cease tobacco consumption in any form for at least 1 month
preoperatively.
Optimize blood glucose level and avoid hyperglycemia.
Patients are to shower/bathe with antiseptic on at least the night before
surgery.
Necessary blood products may be administered.
Gradual reduction/discontinuation steroid use before elective surgery
Enhanced nutritional intake solely to prevent SSI
Preoperative topical antibiotic use in nares to prevent SSI
Measures to enhance wound space oxygenation
Surgical team members
Keep fingernails short; do not wear artificial nails.
Scrub hands and forearms as high as the elbows for at least 2-5 minutes with
appropriate antiseptic.
After scrub, keep hands up with elbows flexed and away from the body; use a
sterile towel to dry the hands and put on a sterile gown and gloves.
29
Masks should be worn in the operating suite if sterile instruments are exposed
and throughout the surgical procedure. Masks should cover the mouth and
nose.
The hair on the head and face is to be covered with a hood or cap.
Liquid-resistant sterile surgical gowns and sterile gloves are to be worn by
scrubbed surgical team members.
Visibly soiled gowns are to be changed.
Shoe covers are not necessary.
Routine exclusion of personnel colonized by organisms such as
Staphylococcus aureus or group A streptococci is not necessary unless they
are specifically linked to dissemination of such organisms.
Personnel with skin lesions that are draining are to be excluded from duty until
treated and the infection has resolved.
Educate and encourage surgical personnel regarding reporting illness of
transmissible nature to supervisory and occupational health personnel.
Policies should be established concerning patient care responsibilities for
personnel with potentially transmissible infective illnesses. This should
include aspects of work restrictions, personnel responsibility in utilizing health
services and declaring illness. Policies also should direct the responsible
person to remove personnel from duty and policy should be established for
clearance to resume work.
Clean under the fingernails prior to the first scrub of the day.
Do not wear arm/hand jewellery.
Restriction of scrub suits to the operating theater.
Covering the scrub suits when outside the theater.
How or where to launder theater suits.
30
Preoperative and postoperative wound care
Asepsis is necessary in the insertion of indwelling catheters, such as
intravascular, spinal, or epidural catheters, and subsequent infusion of drugs.
Handle tissues gently with good haemostasis, minimize foreign bodies and
minimize devitalized tissue and dead space.
For Class III and IV wounds, use delayed closure or leave the wound incision
open to heal by secondary intention.
If draining of a wound is necessary, the drain exit should be via separate
incision distant from the wound. Remove the drain as soon as feasible.
Primary closed incisions should be protected with a sterile dressing for 24-48
hours.
Hands are to be washed before and after wound dressing changes/or contact.
Use sterile technique for wound dressing change.
Educate the patient and relatives regarding the symptoms of SSIs and the need
to report such problems.
Theater environment and care of instrumentation
Maintain positive pressure ventilation of the operating suite relative to
corridors and surrounding areas.
Maintain a minimum of 15 air changes per hour, with a minimum of 3 being
fresh air.
Appropriate filters (as recommended by the American Institute of Architects)
should be used for filtration of all air, whether recirculated or fresh.
Air should enter through the ceiling and exit near the floor.
Keep operating room doors closed except for necessary entry.
31
The use of ultraviolet lamps in the theater is not necessary as a deterrent of
SSI.
Prior to subsequent procedures, visibly soiled surfaces should be cleaned with
Environmental Protection Agency (EPA) approved disinfectants.
Following a contaminated or dirty procedure, special cleaning or closure of the
operating suite is not necessary.
Use of tacky mats prior to entry in the operating suite is not necessary.
Sterile surgical instruments and solutes should be assembled just prior to use.
All surgical instruments should be sterilized according to guidelines. Flash
sterilization should only be used for instruments that are required for
immediate patient use.
Limit the number of personnel entering the operating suite.
Orthopedic implant surgery should be performed in an ultra clean air
environment.
Wet vacuum the floor of the operating theater at the end of day/night using an
EPA-approved disinfectant.
Special situations
Elective colon surgery: Bowel surgery results in the breakdown of the
protective intestinal mucous membrane, with release of the facultative and
anaerobic bacteria that heavily colonize the distal small bowel and colon.
Eradication of aerobes and anaerobes is necessary to reduce infective
complications following intestinal procedures. Mechanical cleansing and
antibiotics could achieve this. Mechanical cleansing for colonic surgery can
take the form of dietary restrictions; whole gut lavage with one of several
32
preparations, such as 10% mannitol solution or polyethylene glycol, usually
performed on the day of surgical intervention. Enteral antibiotic regimes to
eradicate intrinsic bowel flora vary, with oral neomycin and erythromycin
being the most popular combination used in the United States. Other
combinations with neomycin include the use of metronidazole and
tetracycline. Prophylactic parenteral antibiotics also are used with the above.
Intravascular device-related infections: Intravascular devices are of vital use in
daily hospital practice. They are used for the parenteral administration of
fluids, blood products, nutrition fluids, medications, access to hemodialysis
and equally important is their use in the monitoring of critically ill patients.
Unfortunately, because their use constitutes an invasive procedure, they are
associated with infectious complications that could be of a local or systemic
nature.
Recommendations for prevention (Pearson, 1995)43 and treatment (Mermel,
2001)43 are available to limit their associated morbidity and mortality (which
could be as high as 20% in patients with catheter-related bloodstream
infections).
Surgical Care:
Although the goal of every surgeon is to prevent wound infections, they still
occur. Treatment is individualized to the patient, the wound, and the nature of the
infection. The operating surgeon should be made aware of the possibility of infection
in the wound and determine the treatment for the wound.
Such treatment often involves opening the wound, evacuating pus, and
cleansing the wound. The deeper tissues are inspected for integrity and for a deep
33
space infection or source. Dressing changes allow the tissues to granulate, and the
wound heals by secondary intention over several weeks.
Further Inpatient Care:
Resultant increased hospital stay due to SSI has been estimated at 7-10 days,
increasing hospitalization costs by 20% (Haley, 1981).
Occasionally, further intervention in the form of wound debridement and
subsequent packing and frequent dressing is necessary to allow healing by
secondary intention.
Further Outpatient Care:
Most patients with wound infections are managed in the community.
Management usually takes the form of dressing changes to optimize healing,
which usually is by secondary intention.
34
MATERIALS AND METHODS
This is a prospective study which was done in DEPARTMENT OF
SURGERY, at BASAWESHWARA TEACHING AND GENERAL HOSPITAL
attached to M. R. MEDICAL COLLEGE, KALABURGI from November 2015 to
June 2017. A total of 150 patients who underwent elective abdominal surgeries for
various causes were included in the study.
The aim of the study was to evaluate the outcome of surgical site infection in
elective abdominal surgeries with and without a gauze piece kept as drain
subcutaneously and to evaluate different causal factors for SSI in elective abdominal
surgeries in our hospital setup.
Inclusion criteria:
All patients between the age group of 15 years to 75 years who underwent
elective abdominal surgeries for various causes were included in the study.
Exclusion criteria:
Patients with preexisting skin infections were excluded from the study.
Patient selection:
All patients between the age group of 15 years and 75 years who were
admitted for elective abdominal surgeries for various causes were included in the
study. Patient were explained about the pathology, the need for surgery and the
complications associated with it in their own understandable language; informed
consent was taken, ethical committee clearance was obtained.
35
Pre-operative preparation:
Shaving of the operative area was done the night before surgery. All patients
were advised to take shower on the day of surgery with soap.
Aseptic precautions in operation theatre:
All aseptic precautions were taken in operation theatre like proper scrubbing
of hands of operating surgeons, assistant surgeon, scurb nurse; and using autoclaved
gowns, drapes, sterile gloves and instruments.
Operative precautions:
The operative area was painted with 5% povidine iodine, spirit. The principles
of surgeries were followed in all cases such as minimal tissue handling, maintenance
of adequate hemostasis. A gauze piece was kept in subcutaneous plane, Then
subcutaneous layer and skin were closed with sutures.
Post operative care:
Injection ceftriaxone and injection metronidazole were administered in most
of the cases following surgery in the postoperative period. The sub cutaneous drain
was removed on the second post-operative day and the wound was inspected for any
evidence of surgical site infection from 3rd post-operative day till the 10th post-
operative day with regular dressings and discharged with regular follow up. The
criteria for SSI was based on CDC’s definition. For patients who satisfied the criteria
with signs of infection, wound swab was taken and sent for culture and sensitivity,
based on the isolated organism and sensitivity report, antibiotics were changed. If any
36
wound gaping was found during the hospital stay or during follow up secondary
suturing was planned accordingly.
The CHI SQUARE test were used to analyze the data.
Data was collected for patient demographics, clinical information, underlying
disease, surgical procedures, antimicrobials used, infecting pathogens and their
antimicrobial susceptibility patterns and the evidence of SSI.
RESULT
TABLE NO. 1: GENDER DISTRIBUTION
Sl
no GENDER N(%) MEAN ±
SD RANGE MINIMUM MAXIMUM
1 MALE 86(42.30) 30.49 ±15.01
60 15 75
2 FEMALE 64(57.70) 25.82 ± 13.92
60 15 75
3 OVERALL 150(100) 28.52 ±14.69
60 15 75
Interpretation: The mean age of males & females were 30.49 ±15.01 &
25.82 ± 13.92 years respectively.
FIGURE NO .1: GENDER DISTRIBUTION
MALE42%FEMALE
58%
GENDER DISTRIBUTION
38
TABLE NO. 2 CO-MORBID CONDITION Sl no CONDITIONS N %
1 ACUTE KIDNEY INJURY DUE TO SNAKE BITE FOR WHICH DIALYSIS DONE 01 0.67
2 DIABETES 02 01.34 3 HYPERTENSION 08 05.36 4 DIABETES AND HYPERTENSION 06 04.02 5 RENAL CALCULI 01 0.68 6 UTERINE DIDELPHYS 01 0.68 7 NIL 130 87.25 8 OVERALL 150 100
FIGURE NO .2: COMORBID CONDITION
1 2 8 6 1 1
130
020406080
100120140
No.
of C
ases
COMORBID CONDITION
39
TABLE NO. 3: INDICATION FOR SURGERY
Sl no TYPE OF SURGERY N %
1 APPENDICITIS 126 84.56
2 CHOLELITHIASIS 24 15.44
3 OVERALL 150 100
40
TABLE NO. 4: TYPE OF ANAESTHESIA Sl no TYPE OF ANAESTHESIA N %
1 GENERAL ANAESTHESIA 24 15.40
2 SPINAL 126 84.60
3 OVERALL 150 100
TABLE NO. 5: SURGERY DONE
Sl no TYPE OF SURGERY DONE N %
1 APPENDECTOMY 126 84.60
2 CHOLECYSTECTOMY 24 15.40
3 OVERALL 150 100
FIGURE NO.3: TYPE OF SURGERY
APPENDECTOMY, 85
CHOLECYSTECTOMY, 15
TABLE NO. 6: DRAIN
Sl no DRAIN N %
1 KEPT 75 49.70
2 NOT KEPT 75 50.30
3 OVERALL 150 100
Interpretation: Patients were equally divided in both the groups; 75 patients
with and 75 patients without drain.
FIGURE NO.4: PLACEMENT OF DRAIN
DRAIN KEPT50%
DRAIN NOT KEPT50%
TABLE NO. 7: SIGNS OF INFECTION
Sl no SIGNS OF INFECTION N %
1 ABSENT 124 82.60
2 PRESENT 26 17.40
3 OVERALL 150 100
Interpretation: Very few had signs of infection present.
FIGURE NO.5: SIGNS OF INFECTION
ABSENT83%
PRESENT17%
44
TABLE NO. 8: CULTURE AND SENSITIVITY
Sl no N %
1 E COLI 20 13.42
2 KLEBSIELLA PNEUMONIAE 03 02.03
3 P. AUEROGINOSA 01 0.67
4 STAPYLOCOCCUS AUREUS 01 0.67
5 NIL 125 83.21
6 OVERALL 150 100
FIGURE NO.7: CULTURE AND SENSITIVITY
20
3 1 1
124
0
20
40
60
80
100
120
140
E COLI KLEBSIELLA PNEUMONIAE
P. AUEROGINOSA STAPYLOCOCCUS AUREUS
NIL
Chart Title
TABLE NO. 9: OVERALL RATE OF SURGICAL SITE INFECTION
Sl no N %
1 INFECTED 20 13.33
2 UNINFECTED 130 86.66
3 TOTAL 150 100
Interpretation: 20(13.33%) cases were infected when compared to 130
(86.66%) uninfected.
FIGURE NO.6: OVERALL RATE OF SURGICAL SITE INFECTION
WITH DRAIN WITHOUT DRAIN 75 75
NOT INFECTED INFECTED NOT INFECTED INFECTED 65 9 65 11
PERCENTAGE INFECTED
6% PERCENTAGE INFECTED
7.3%
Patients with drain had 6% infection. Those without drain had 7.3% infection.
INFECTED13.36%
NON INFECTED86.66%
RESULT
46
TABLE NO. 10: TYPE OF SURGERY & RESULT
SURGERY DONE RESULT
INFECTED NOT INFECTIVE
APPENDICECTOMY 13 113
CHOLECYSTECTOMY 7 17 Interpretation: Appendicectomy had 8.6% infection; while cholecystectomy had 4.6% infection rate.
TABLE NO. 11: CO-MORBID CONDITION & RESULT
CO-MORBID CONDITION
RESULT Chi square value P value Relative
risk
INFECTED NOT INFECTIVE
10.278 0.00112
3.76(1.68-8.41) PRESENT 07 13
ABSENT 13 117
Interpretation: Those who had comorbid condition present along with the
required surgery were 3.76 times more likely to get infected when compared to those
who didnt have.
TABLE NO. 12: DRAIN & RESULT
DRAIN
RESULT Chi square value P value Relative
risk
INFECTED NOT INFECTIVE
0.46 0.83 0.91(0.39-2.11) KEPT 09 65
NOT KEPT 11 65
Interpretation: Cases in which drains were kept had 1.3% less chances of
getting infected than those without drain.
47
TABLE NO. 13: SIGN OF INFECTION & RESULT
SIGNS
OF INFECTION
RESULT Chi square value P value Relative
risk P value
INFECTED NOT INFECTIVE
103.22 <0.001
179.11 (11.15-
2875.96) 0.002 PRESENT 19 07
ABSENT 0 124
Interpretation: Those who had signs of infection present were 179.11 times
more likely to be infected than those who didnt have any sign of infection
TABLE NO. 14: SIGNS OF INFECTION & DRAIN
SIGNS OF INFECTION
DRAIN Chi
square value
P value Relative risk (95%CI) P value
KEPT NOT KEPT
0.155 0.694 0.91(0.58-1.43) 0.70 PRESENT 12 15
ABSENT 62 61
48
DISCUSSION
Surgical site infections is one of the most serious infective complications of
surgery. Study consideration is to remove the blood and serous fluids from the wound
by drains before fluids can get infected.44This concept is frequently implemented in
clinics. However, a meta-analysis showed that prophylactic subcutaneous drainage to
prevent wound complications is not efficient in gynecology.45 Laprotomies carry a
higher risk of wound infection and a combined rate of 15% has been reported in upper
and lower gastrointestinal surgery, over three times the average risk.47 On the other
hand, there have so far been few reports on the efficacy of prophylactic subcutaneous
drain for the prevention of SSI following elective surgery. It is generally thought that
the incidence of SSI is related to amount of bacterium of the wound, formation of
hematoma, pool of effusion, potential subcutaneous dead space, disturbance of the
local circulation, and the amount of bacterium in the surgical organ.46
A subcutaneous drain might reduce the amount of bacterium around the
wound and remove residual effusion and blood from the wound that could serve as a
medium for bacterial growth.
Numerous risk factors for developing a SSI have been identified. Current
smokers are at a 30% increased risk of SSI after major surgical procedures and
smoking cessation reduces SSI.48,49 Body Mass Index and obesity have also been
linked to increased risk of SSI with studies showing wound complication rates in
some procedures rising from 7% up to 23% due to obesity.50,51 More specifically,
depth of subcutaneous fat has been shown to be a strong risk factor for SSI and has
been shown to be a useful predictor for SSI risk.52,53 Many other factors including
49
nutrition and diabetes control, certain comorbidities, ASA class, and operation time
have been identified as important factors affecting SSI.53,54
Various interventions have been proposed with a view to reducing SSIs. A
number of them are used in routine practice. Hand washing, minimising shaving, skin
preparation, and preoperative antibiotics have all gained acceptance in the surgical
community.55 Use of drains after surgery however has declined in recent times. It has
been shown that drains provide no advantage after inguinal hernia repairs, and various
other types of surgery.56 Use of drains, however, is still popular after
abdominoperineal excision of rectum and repair of incisional hernias due to
inconclusive evidence and surgeon preference.57 They are still used in some major
plastic surgery procedures as they are thought to reduce collections in closed spaces.58
It has been postulated that the presence of hematoma, serous fluid, and dead
space in surgical incisional wounds increases the risk of infection as this acts as a
culture medium.59 Subcutaneous drains have been used to reduce the risk of infection.
However, the use of postoperative subcutaneous wound drainage is not universally
accepted. In addition, drains may not be efficacious and cause discomfort and
increased hospital stay on their own.
The present study had overall infection rate of 13.3% which was comparable
with the studies Raka et al; Razavi et al; Rajesh et al where the incidence were 12%,
17.4%, 37% respectively. Those with the drain group had 1.3% less chances of
getting infected with relative risk 0.91(0.39-2.11) compared with non drain,
comparable with the study of Nisar Ahmed chowdary et al; where 5.2% less chance in
drain group compared with non drain.
50
In a transitional economy like India, even a small reduction in SSI by
introduction of a simple cost-effective subcutaneous drain will go a long way in
reducing the economic burden of SSI on healthcare. These drains are cheap, simple to
insert, don’t require any special skills or technique, are not known to cause any harm
to the patient and easy to remove. Though their effectiveness in preventing SSI is still
a matter of debate, their use may be propagated at least in emergency setting where
degree of contamination is high. However more studies are required to study the role
of subcutaneous drains in elective abdominal surgeries.
51
CONCLUSION
The study was done with aim of reducing the surgical site infections and thereby
reducing morbidity, cost, duration of hospital stay and psychological stress the patient
experience. Many novel techniques are implemented in decreasing the incidence of
surgical site infection like preparing the patient for surgery, administration of
antibiotics prophylactically when necessary, the use of subcutaneous drain before
closing the skin incision followed by post operative administration of broad spectrum
antibiotics, maintainance of adequate nutrition and removal of drain after 48 hours,
regular dressing and follow up.
The drain placed subcutaneously act as a channel to drain out secretion that are
likely to collect in the subcutaneous tissue following clousure of the incision in the
immediate post-operative period. There by reducing the chance of hemotoma
formation, seroma formation that might get infected in due course of time to cause
wound dehiscence increasing the morbidity, duration of hospital stay, cost.
In this study patient with drain has 6.0% infection and without drain had 7.3%
infection.
Thus by keeping the drain in the subcutaneous tissue we facilitate the drainage of
subcutaneous collection, early detection of infection and faster management of
surgical site infection there by reducing the cost, hospital stay morbidity.
SUMMARY
Overall:
The mean age of males and females in the study were 30.49+/-15.0 1 years and 25.82+/-13.9
years respectively.
Patients were equally divided in both the groups 75 patients with drain and 75 patients
without drain.
Very few had signs of infection.
20 (13.36%) cases were infected when compared to 130 (86.66%) uninfected cases.
Most commonly isolated organism was E.coli.
In patients with drain and without drain:
Patients with drain had 6.0% infection , those without drain had 7.3% infection.
Of the surgeries patients underwent appendicectomy had 8.6% infection while
cholecystectomy had 4.6% infection.
Patients who underwent surgery with co-morbid conditions along with required surgery had
3.76 times more chances of infection than patients who donot had co- morbid conditions.
Patients with drain had 1.3% less infection than patient without drain.
Patients with signs of infection had 179.11 times infection rate than those who didn’t had any
signs of infection
52
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59
PROFORMA FOR STUDY
NAME:
AGE:
SEX:
ADDRESS:
IP NO:
DATE OF ADMISSION:
DATE OF SURGERY:
DATE OF DISCHARGE:
PRE-OPERATIVE STATUS:
CO-MORBID CONDITIONS:
OPERATIVE DETAILS:
INDICATION FOR SURGERY:
TYPE OF ANAESTHESIA:
SURGERY DONE:
TYPE OF DRAIN KEPT:
1. CORRUGATED DRAIN: 2. VACCUM DRAIN: 3. GAUGE PIECE:
DURATION OF SURGERY:
POST OPERATIVE STAY:
POST OPERATIVE DETAILS:
A B C D E F ANTIBIOTIC USED
DURATION OF USE
TIME OF DRAIN REMOVAL
60
EXAMINATION OF WOUND:
POST OP DAY
FOR REDNESS LOCAL RISE OF TEMPERATURE
TENDERNESS WOUND SITE
SWELLING OR EDEMA
DISCHARGE
3RD
DAY
4TH
DAY
5TH DAY
6TH DAY
7TH
DAY
8TH
DAY
9TH DAY
10TH
DAY
PUS FOR CULTURE AND SENSITIVITY:
REPORT:
Surgical wound before the closure of subcutaneous layer and skin.
Placement of drain in the subcutaneous plane before the closure of
subcutaneous tissue and skin
Closure of subcutaneous layer with the placement of drain
Closure of skin with subcutaneous drain in situ
Removal of drain on second post operative day