International Journal of Biological & Medical Research

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1 Int J Biol Med Res. 03; (): Int J Biol Med Res Volume 3, Issue, Jan 0 BioMedSciDirect Publications Contents lists available at BioMedSciDirect Publications International Journal of Biological & Medical Research Journal homepage: International Journal of BIOLOGICAL AND MEDICAL RESEARCH Original Article A study of comparison of infection rate among various surgical site infection cases in a tertiary care hospital Prasannagupta Assistant professor, Department of Microbiology Konaseema Institute of Medical Sciences, Amalapuram- 330, Andhra Pradesh, India A R T I C L E I N F O A B S T R A C T Keywords: Surgical site Infection(SSI);India Backround - surgical site infections (SSIs) are associated with increased morbidity and mortality as they can cause delay in recovery, increase length of stay, increase health care costs.this study was conducted to find out the prevalence of surgical site infection among various emergency and elective post surgical cases at a Medical College. Methodology - The study was conducted in the Department of Microbiology, Medical College, Calicut for a period of one year from July 007 to June 008. The total number of surgeries done during the one year period in three surgical units were 90. One hundred and two cases of clinically suspected postoperative wound infection from the above cases was studied in detail. The study included 7 'clean', 3 'clean-contaminated', 3 'contaminated' and 30 'dirty' cases. Two swabs were collected from each site. One swab was used for direct smear examination after Gram staining and second swab was subjected to culture and antibiotic sensitivity testing by standard microbiological techniques. Results - The incidence of postoperative wound infection was.%. Among one hundred and two clinically suspected cases studied, bacteriologically proven surgical site infection was identified in thirty six patients. The prevalence of infection being 3% (/0).Lowest infection rate was seen in clean(8.%) surgery followed by clean-contaminated(37.%), contaminated(38.%) and dirty surgeries(7%). MRSA (Methicillin resistant ) and multidrug resistant gram negative bacilli were predominant isolate. Conclusion -. The prevalence of infection being 3% ).Lowest infection rate was seen in clean surgery(8.%) followed by clean-contaminated(7.%), contaminated(37.%) and dirty surgeries(7%). MRSA (Methicillin resistant Staphylococcus aureus) and multidrug resistant gram negative bacilli were predominant isolate. c Copyright 00 BioMedSciDirect Publications IJBMR - ISSN: 0976:668. All rights reserved.. Introduction The inflammatory response is a protective mechanism that aims to neutralize and destroy any toxic agents at site of injury and restore tissue homeostasis.[] There are a number of indicators of infection. These include the classical signs related to the inflammatory process and further more subtle changes as highlighted by Cutting and Harding.[] The classical signs of infection include:localised erythema,localised pain, Localised heat,cellulitis,oedema. Further criteria include:abscess,discharge which may be viscous in nature, discoloured and purulent,delayed healing not previously * Corresponding Author : Dr. Prasanna Gupta Assistant professor Dept. of Microbiology, Konaseema Institute of Medical Sciences Amalapuram- 330, Andhra Pradesh, India Mob.No E mail id: pramin@yahoo.co.in, anticipated, Discolouration of tissues both within and at the wound margins,friable, bleeding granulation tissue despite gentle handling of and the non adhesive nature of wound management materials used.unexpected pain and /or tenderness either at the time change of dressing or reported by the patient as associated specifically with the wound even when the wound dressing is in place.abnormal smell.,wound breakdown associated with wound pocketing / bridging at base of wound, i.e., when a wound that was assessed as healing starts to develop strips of granulation tissue in the base as opposed to a uniform spread of granulation tissue across the whole of the wound bed.the above criteria should be used as discriminating factors when the 'classic' signs of wound infection do not appear to be present but the presence of a wound infection is suspected. Surgical wounds are classified based on the presumed magnitude of the bacterial load at the time of surgery[3] c Copyright 00 BioMedSciDirect Publications. All rights reserved.

2 Prasannagupta Int J Biol Med Res. 03; (): Wound class, Representative Procedures, and Expected Infection Rates Clean (Class I) Hernia repair, breast biopsy.0-. % Clean-contaminated (Class II) Contaminated (Class III) Dirty (Class IV) Cholecystectomy, elective GI surgery Penetrating abdominal trauma, large tissue injury, enterotomy during bowel Perforated diverticulitis, necrotizing soft tissue infections.-9.% 3.-3.% 3.-.8%. Material and Methods The study was conducted in the Department of Microbiology, Medical College, Calicut for a period of one year from July 007 to June 008. Patients from three surgical units S, S3 and S were subjected to the study. The total number of elective and emergency surgeries done during the one year period in the above three units was 90 which included 07 elective (major) and 88 emergency cases. One hundred and two cases of clinically suspected postoperative wound infection (Fifty nine elective and fourty three emergency) from the above cases was studied in detail. The study included twenty seven 'clean', thirty two 'clean-contaminated', thirteen 'contaminated' and thirty 'dirty' cases.clean cases included were Surgeries like herniorrhaphy (6), mastectomy (6), thyroidectomy (), lipoma excision (). Surgeries like 'appendicectomy (), gastrojejunectomy (), gastrectomy (), h e p a t i c o j e j u n e c t o my ( ), t r i p l e a n a s t o m o s i s ( ), choleccystectomy (), APR for ca rectum (7), trendlenberg operation (), mastectomy for advanced ca breast (3), tracheal resection () were included in the Clean-contaminated' group.'contaminated' cases included laparotomy (7), laparotomy for blunt injury to abdomen (), laparotomy with Hartman's procedure (), laparotomy with colostomy (), exploratory laparotomy with excision of fistula (), laparotomy with hysterectomy (), laparotomy with subtotal gastrectomy ().'Dirty' cases included laparotomy for perforation peritonitis (8), laparotomy for obstructed and irreducible hernia (6), abscess incision and drainage (), paraumbilical hernia with appendicular abscess (), laparotomy for burst abdomen (), laparotomy for intestinal obstruction (), laparotomy with resection of gangrenous colon(). Samples were collected from patients with suspected surgical site infection, using sterile cotton swabs. Swab was taken if there was any suspicion or evidence of wound infection as indicated by local inflammation or discharge. The wound was thoroughly irrigated with sterile normal saline until all visible debris had been washed away. Loose necrotic slough, if any, was also removed. Care was taken not to clean the wound with betadine or any other antiseptic solution before swabbing the area. The area selected was the highly vascular granulation tissue rather than the yellow fibrous slough. The material was collected by pressing the swab over the clean wound surface to extract tissue fluid as this may contain the potential pathogen [,] Two swabs were collected from each site. One swab was used for direct smear examination after Gram staining. The second swab was subjected to culture and antibiotic sensitivity testing by standard microbiological techniques. The swab was plated on. Blood agar. Mac Conkey's agar Blood agar plates were incubated in the candle jar (CO) at 370c for hours. A sterile report was given only after 8 hours of incubation. From the culture plates, Gram stained smears were made from different types of colonies after noting the colony characteristics. Identification of bacteria was carried out as described by Koneman[09] Antibiotic sensitivity testing of the isolates was done by the Stokes method for Staphylococcus and Kirby Bauer method for Gram negative bacilli. The following antibiotic discs were used for sensitivity testing of Gram positive cocci : Penicillin (0units), E r y t h r o m y c i n ( m c g ), G e n t a m i c i n ( 0 m c g ), Vancomycin(30mcg), Cefazolin(30mcg). Oxacillin screen agar was used for Staphylococci. Ampicillin(omcg), Gentamicin(0mcg), Cefazolin(30mcg), Ceftriaxone(30mcg), Amikacin(30mcg), Ciprofloxacin(mcg) were used for sensitivity testing of Gram negative bacilli. For Pseudomonas Ceftazidime (30mcg) was also used. In 0 cases a repeat swab was taken and processed as there was a delay in wound healing and poor response to treatment.all cases were followed upto the date of discharge. Condition of the wound was noted at the time of discharge from the hospital. 3. Results The table presents the types of surgeries included in this study. The incidence of postoperative wound infection was.%. Among one hundred and two clinically suspected cases studied, bacteriologically proven surgical site infection was identified in thirty six patients. The prevalence of infection being 3% (/0). In the 'clean' surgical group, five patients developed infection,the prevalence was 8.%. Prevalence of Infection in the 'clean-contaminated' group was 37.% (/3). In the 'contaminated' group it was 38.% (/3) and in the 'dirty' group it was 7% (/30). The The.table - presents the prevalence of infections in clean, clean-contaminated,

3 Prasannagupta Int J Biol Med Res. 03; (): contaminated and dirty surgeries. The table 3 a and 3b depicts the results of culture & type of organism causing infection.the table a presents the relationship between the type of surgery and organism in thirty one cases which were Infected with single organism while table b presents Infection with multiple organisms. Mixed bacterial infection was observed in five cases. These were three cases of laparotomy, one case of and one case of trendlenberg operation. Infection with Escherichia coli and occurred in one case of, and in two cases of laparotomy. Pseudomonas aeruginosa and E. coli mixed infection was seen in one case of laparotomy. Infection with Acinetobacter baumannii, Pseudomonas aeruginosa and occurred in one case of trendlenberg operation. (Tableb). The table depicts sensitivity pattern of the isolates in this study. MRSA (Methicillin resistant ) and multidrug resistant gram negative bacilli were predominant isolate. Table : Types of surgeries included in the study(n=0) Table 3a: Results of culture (n=0) Clean Clean-contaminated Finding No No Sterile Herniorrhaphy Mastectomy Thyroidectomy Lipoma excision Contaminated Appendicectomy Gastrojejunectomy Gastrectomy Trendlenberg operation Hepaticojejunectomy Tracheal resection Cholecystectomy Mastectomy for advanced Ca breast Triple anastomosis Dirty Colonization Infection Gram Positive Gram Negative Polymicrobial 0 Type of organisms causing infection in cases is shown in table 3b Table 3b Type of Organism 7 39% 7% % 7 for perforation peritonitis 8 00% for blunt injury to abdomen with Hartman's procedure Laparoto with colostomy with excision of fistula Laparoto with hysterectomy with subtotal gastrectomy 3 for obstructed and irreducible hernia Abscess incision and drainage Paraumbilical hernia with appendicular abscess for burst abdomen and resection of gangrenous colon for intestinal obstruction 6 30 Table a Relationship between the type of surgery and organisms in thirty one cases which were Infected with single organism Type of Organism Hernia repair Infected no of cases 7 Organisms isolated Pseudomonas aeruginosa Klebsiella oxytoca Enterobacter intermedius Enterobacter Kobei No.of isolates Table : Prevalence of infections in clean, clean-contaminated, contaminated and dirty surgeries(n=0) Mastectomy Appendicectomy Category of surgery Clean Clean-contaminated Contaminated Dirty No.of clinically suspected cases with infection Prevalence of infection (%) Abscess I & D Cholecystectomy Tracheal resection Lipoma excision, Serratia marcescens 0 3

4 Prasannagupta Int J Biol Med Res. 03; (): Table b: Infection with multiple organisms No. Organisms isolated, Pseudomonas aeruginosa,, Trendlenberg operation Acinetobacter baumannii, Psuedomonas aeruginosa, Table: ABST pattern of the isolates in (%)(n=) Antibiotic P S. aureus E. Coli Entero Pyo Kleb Serratia Acineto 8 bacter E G A Va 00 Cf. 00 Cefta Ox 7.7 Pip M Cip 0 00 Ceftri 00 Abbreviations - P-Penicillin,E-Erythromycin,G-Gentamicin,VaVancomycin,Cf-Cefazolin. A-Ampicillin,G-Gentamicin,CeftriCeftriaxone,Ak-Amikacin,Cip-Ciprofloxacin, Cefta- Ceftazidime, Not tested, ABST - Antibiotic sensitivity testing A Appendicectomy B Tracheal resection C Mastectomy for advance Ca breast D E Gastro jejunectomy F Gastrectomy G Trendlenberg operation H Hepatico jejunectomy I Triple anastomosis J Cholecystectomy

5 Prasannagupta Int J Biol Med Res. 03; (): A E with excision of fistula B for blunt injury abdomen F with hysterectomy C with Hartman's procedure D with colostomy G with subtotal A- for perforation peritonitis B for obstructed irreducible hernia C Abscess incision and drainage D Paraumbilical hernia with appendicular abscess E for burst abdomen F and resection of gangrenous sigmoid colon G for intestinal obstruction. Discussion The incidence and pattern of wound infection varies from centre to centre. In the present study the incidence of postoperative wound infection is.%.of the one hundred and two clinically suspected cases of post operative wound infection studied. Prevalence of infection in the study group is 3%. The prevalence of postoperative wound infection among 'clean' cases was 8.%, 'clean-contaminated' 37.%, 'contaminated' 38.% and 'dirty' 7%.[figure ] Infection rate of various surgeries have been depicted in figure,3,,. Topley and Wilson reports an infection rate less than % for 'clean' surgeries and 30% for 'clean-contaminated' type of operations. According to Schwartz, it is less than % for clean cases and around 30% for 'cleancontaminated' surgeries. Charles D Ericsson also reports a similar rate of % for clean surgeries and to 0% for 'clean-contaminated' cases.[6] An overall infection rate of.3% is reported by Yalcin et al in his study conducted at Cumhuriyet University Medicine Faculty Hospital in Turkey between January 99 and December 993.[7] The incidence of post surgical clean wound infection in 0 consecutive operations were found to be only.98% by Ako-Nai et al in his study on a Nigerian hospital[8] An overall infection rate as high as 3.37% is reported by Saha SC et al from East Africa from his study on 0 postoperative patients. According to a study the incidence of SSIs with regard to abdominal surgical sites and operating conditions is as follows: clean wounds (.-3.7%), clean contaminated (3-%), contaminated(8.%) and dirty-infected wounds (8-0%).[9]. Conclusion Surgical site infection is an important aspect of nosocomial infections which is a serious problem in hospital practice. The study was selected to find out the pattern of surgical site infection among various clean, clean contaminated,contaminated and dirty surgeries and to study the sensitivity pattern of isolates of surgical site infection.. The prevalence of infection being 3% ).Lowest infection rate was seen in clean surgery(8.%) followed by clean-contaminated(7.%), contaminated(37.%) and dirty surgeries(7%). The incidence of post operative wound infection was.%. The prevalence rate of post operative wound infection among study group was 3%. The most important isolate in the study was in clean surgeries. In clean-contaminated, contaminated and dirty surgery cases multidrug resistant E.coli and (MRSA) were the main pathogens followed by Pseudomonas, Enterobacter, Acinetobacter and Klebsiella.The type of surgeries had an important role in determining the pattern of wound infection. Acknowledgments Funding: None. I wouldlike to express my sincere gratitude to Dr. Beena philomina J., associate professor department of microbiology Calicut medical college, kerala for her contribution and support during this work. 6. References [] Coller M. Understanding wound inflammation. Nurs Times 003; 99(): [] Cutting K, Harding K. Criteria for identifying wound infection. J wound care 99; 3(): [3] Martone WJ, Nichols RL. Recognition, prevention, surveillance and management of surgical site infections. Clin Infect Dis 00; 33: S67. [] Marrian FA and Meyer L. Surgical site infection rates in patients who undergo elective surgery on the same day as their hospital admission. Infect Control Hosp. Epidemiol 998 May; 9(): extbook of operative surgery. 99; 8th edn: 8-3. [] Rintoul RF, Farqujarson's textbook of operative surgery. 99; 8th edn: 8-3. [6] Ericsson CD and Rowlands BJ. Surgical infection: Principles and management of antibiotic usage. Physiologic basis of modern surgical care. 988; 3-3. [7] Yalcin AN and Bakir M. Postoperative wound infections. Journal of Hospital Infection 99; Apr 9(): [8] Ako-Nai AK, Adejuyigle O, Adewumi TO and Lawal. Sources of intraoperative bacterial colonization of clean surgical wounds and subsequent postoperative wound infection in a Nigerian Hospital. East Afr Med J 99 Sep; 69(9): [9] Abdominal surgical site infections : incidence and risk factors at an Iranian teaching hospital. Seyd Mansour Razavi, Mohammad Ibrahimpoor, Ahmad Sabouri Kashani and Ali Jafarian BMC surgery 00, : online at www. Biomed central.com/7-8// c Copyright 00 BioMedSciDirect Publications IJBMR - ISSN: 0976:668. All rights reserved.