Prevention of

Surgical Site Infection

Muhammad Ilham Aldika Akbar, dr. SpOG(K)
Departemen Obstetri dan Ginekologi RSUD
Dr. Soetomo – RS. UNAIR
Fakultas Kedokteran UNAIR

Workshop Pencegahan Infeksi dan Pemakaian Antibiotika Rasional, 19 Juli 2018, Semarang
dr. Muhammad llham Aldika Akbar SpOG(K)
Institution:

• Staff P.~OOr.t(tffilm QQgyl) RS UNAIR - RSUD Or. Surabaya

Soetomo,
• Lecturer Faculty of Medicine
UNAJR
Position:

• Head of ObGYN Medical $.\~fRS UNAIR

• Research Coordinator Dept Qbgyn RSUD Dr. Soetomo

"M~~tJh
• Vice Editor Journal
P.~~lr:l~lCl~kQIQgj"
Education:

• GP: Faculty of Medicine UNAIR (1999-2005)

• Speclallst Q9gy,:i: RSUD Dr. Soetomo - UNAIR (2007-

2011)
• MFM Consultant: RSUO Dr. Soetomo- UNAIR (2014-
2016)
Special Training:

f~.t~J Medicine Unit A<;t~f!t?rn~.E}. Hospital, Cambridge, (2013

England )

Publication
1 Outcome(FirstLupus
Author):
Nephritis in at Dr. Soetomo Hospital, Indonesi Gynaecology and
. Pregnancy a.
2. Perinatology,
Clinical 1.2 (2018):
Characteristic 120-129
of acute fatty liver in a tertiary irJ.QQmt§ii!D. hospital. J M.~.(~r,11 f..tt.(cA! /:!!!.Q!J.€f.(t
Med. 2017
3. Oct 16:1-191
Characteristic of IUGR cases ar Dr. Soetomo Hospital 2014-2016, and .~er.e.br.QpJa~ental ratio
4. Profile
(CPR) as of screening
patients with post i:2artµm
for detecting .b~ITIPT.rhag~
IUGR. Journal in Dr.
of Obstetrics and Soetomo Hospital,
Gynaecology Surabaya,
Research 43(S1):8, June-
2017.
.Jaf.\Uiid 2011
5. December 2013. Mifiil.lifb. .Ob~.tt:.tri & .Glac.kglag.i, 24(2). Amis.tYS 2016
Comparison between Early-onset and Late-onset Severe Preeclampsia during Onset of The Disease by
Echocardiography Examination of Cardiac Output, Total Vascular Peripheral Resistance, and
Doppler
 DEFINISI

Infeksi pada kulit atau jaringan

subkutis sekitar insisi, atau daerah
operasi < 30 hari pasca prosedur

Memiliki salah satu gejala:

• Cairan purulen dari insisi
• Kultur jaringan atau cairan (+)
• Luka terbuka disertai tanda infeksi (nyeri,
eritema, edema)
 EPIDEMIOLOGI

• Bagian HAI (Health care-associated infection)

• Beban HAI 2-3x di negara miskin-berkembang
• SSI menimbulkan beban morbiditas-mortalitas dan biaya yang
signifikan
• Insiden SSI di negara berkembang 11.8/100 prosedur operasi

Global Guidelines for Prevention SSI; WHO, 2016

The European Center for Disease Prevention
and Control (ECDC), 2010-2011
Jenis Pembedahan Insidens SSI
(100 operasi)
Operasi Colon 9.5 %
Operasi graft bypass arteri koroner 3.5 %
SC 2.9 %
Kolesistektomi 1.4 %
Operasi Prostesi Panggul 1.0 %
Laminektomi 0.8 %
Operasi Prostesi Lutut 0.75 %

Global Guidelines for Prevention SSI; WHO, 2016

Global Guidelines
for Prevention
SSI; WHO, 2016
Counrtry SSI rate ('%) V,ear* Meas,urem,ent used Stud!, design
i(IJ'lefeIJ'len (95,% Cl [when provided0
ce)
IRepubU Overalll: 2. 1 20 10-2011 Curnu l.ati\re ~ncf Na1tional surgital
c Gastrectomy,~ dence sfrtre 1 nfertl on
of 3. 1 (522} 16 918) 2008-2012 (episodes peu 100 surveilLarnce
Korea1 Total. hlp arthroplasty: operations) s.ystem
(35~ 37) 2.0 (157/7656) - lncidence design
Urugucry Appendectomy~: 2014 Cumul.ati\re Na1tional
(42) 3.2. lncidem:e nosocorraat
Cardrac surgery: (eplsodes peu 100 infection
2.5 operations) surveiUanice
Chlole,cystectomy: 6.2 system
crnae (43) Coronary bypass
COtO: 15.4 3.1
2013 National HAI
s1Uuge;ry: infection
H1p joint replacement: 1. 9 surveiUanice
system
lMICs-VVHO Average: 6. 1 1995-2015 Cumulati\re Incidence/prospective
(5.0-7.2) inci'dern:e
(~plsodes, perr 100
South-East 7.8 (6.3-9.3) 200.J-2012
operations)
Pooled 1ncidence Systematit literature
Asia (40) review

~ Year of the most recent publicatton assessing the n.ational 551 rates.
·# Unpubkshed WHO daita.
Global Guidelines for Prevention SSI; WHO, 2016
 Epidemiology SSI
About 80 000 hospitalised patients in Europe have at least one HAI on any
given day
In Europe, SSI are the second most frequent type of HAI (19.6%) – 543 149
(298 167-1 062 673) SSI episodes/year (HAI prevalence survey 2011)
In the US, the overall SSI rate was 0.9% in 2014 (data from 3654 hospitals
over 2 417 933 surgical procedures)
SSI are the most frequent type of HAI on admission (67% in US, 33% in
Europe)
Surgical sepsis accounts for approximately 30% of all septic patients
SSI are the most frequent type of HAIs in LMICs and rates are significantly
higher than in HICs (11%, on average)
 Insidens SSI pada Kasus Obstetri
RSUD dr. Soetomo , Januari 2017 - Mei 2018

Jumlah Kunjungan RSUD Dr

3%
Soetomo
SSI 41
Normal 1560
Total Kunjungan 1601

97%

Non SSI
Kamalia H, Aldika A, 2018 SSI
 Proporsi IDO pada Kasus SC di RSDS
RSUD dr. Soetomo Januari 2017 - Mei 2018

Jumlah Operasi SC di RSUD IDO

Dr Soetomo 1%

IDO 17
Non IDO 1150
Total 1167

Non IDO
99%

Kamalia H, Aldika A, 2018

Rate SSI di Negara Miskin-Berkembang
• WHO report: 5.6 – 11.8 /100 prosedur operasi
• Telaah sistematis WHO (1995-2015): rate SSI 11.2/100 operasi (95%
CI: 9.7-12.8)
• Rate SSI SC bervariasi di berbagai negara:
• Nigeria: 16.2%
• Kenya: 19%
• Tanzania: 10.9%
• Vietnam: 9.7 %
• Brazil: 9.6% dan 23.5%
 Faktor Risiko
Internal (terkait pasien) External (terkait prosedur)
• Obesitas • Durasi operasi lama
• Diabetes • Skor ASA > 3
• Skor luka tinggi • Lama rawat inap sebelum
• Tipe luka (kotor atau operasi > 2 hari
• Tidak mendapat antibiotic
terkontaminasi)
profilaksis
• Usia > 60 tahun • Relaparotomi
• RS dengan beban operasi
rendah (low volume hospital)
 Prog1orsl IDO Rada Kasus SC di RSDS Status HB Progorsl 100 Rada Kasus SC di RSOSBerdasarkan Kadar Albumin
Berdasarkan
RSU dr. Soetomq Januarl 2017 - Mel 2018 RSUO dr. Soetomo Januari 2017 - Mei 2018
D

•Anemia
• Non Anerrua Albumin< 3,4 13
Albumin {3,4-
5,4) 4
TOTAL 18

Albumin < 3,4

76%

Pro orsl 100 Rada Kasus SC di RSOS Berdasarkan e,oporsl IDO pada Kasus SC di
BMI RSDS
Berdasar:Jcan Jumlah Harl Perawaian
RSUOdr. Soetomo Januarl - OeHmber 2017
di RS RSUD dr. Soetomo Januarl
2017 - Mel 2018
Ungecwiegh Underwieght
t
<18 0 Obese Class <1 Normal 18·25
8 u
tor
'-
::111:!cn,:
erweight
3
9
II

°
> 30
hari
11
1 10

" TOTAL 8
mal
bbese Class I
Obese Class II
4
1
8

6
Kamalia H,
pbese Class I
2
~ObeseClass Ill
iTOTA 18 ~ 3~~4 Aldika A, 2018
L ~
0
< 14 hari 14 . 30 hari > 30 hari
 SSI Risk Varies by Operation
Pooled Mean SSI
Operation Rate (%) 25th, 75th Percentile
CABG, Chest and Donor 4.26 1.33, 5.81
Site
Colon 7.06 2.38, 9.09
Abdominal Hysterectomy 4.05 0.00, 4.86
Hip prosthesis 2.40 0.00, 3.70
Laminectomy 2.30 0.00, 3.73
PRe
i skrinpdhexecraatelgoVrays“c2”uolpaerrations 6.98 2.75, 8.47
Bypass
Voluntary Reporting to NHSN

Am J Infect Control 2009; 37:783-805.

 SSI Rate in a Clinical Trial Compared to
NHSN Reported SSI Rates
Ertapenem Cefotetan
Infection N=338 (%) N=334 (%)
Any SSI 62 (18.1) 104 (31.1)
Superficial incisional 45 (13.1) 75 (22.4)
Deep incisional 13 (3.7) 17 (5.1)
Organ-space 4 (1.2) 12 (3.7)

Paling banyak Total infections identified = 166 (24.7%)

jenis superficial Deep incisional and organ-space = 46
incisional (6.8%)

NHSN Pooled Mean = 7.06%

NHSN 90th Percentile = 13.8%
N Engl J Med 2006; 355:2646.
GLOBAL GUIDELINES
FOR THE OF
PREVENTION
SURGICA SIT INFECTIO
L E N

I~\ World Health

~ Organizatio
n
 9 Rekomendasi WHO – Preoperatif
Pasien dengan karier S. aureus di nasal harus mendapat terapi mupirocin 2%
intra nasal preoperative dengan atau tanpa kombinasi mandi CHG
(ChlorHexidine Gluconate).
MBP (Mechanical Bowel Preparation) saja (tanpa pemberian antibiotika oral)
sebaiknya tidak digunakan pada pasien dewasa yang menjalani operasi
kolorektal.
Pada pasien yang menjalani operasi pembedahan, rambut sebaiknya tidak
dicukur, atau jika mutlak diperlukan, dapat dihilangkan dengan clipper.
Pencukuran rambut dilarang pada semua kondisi, baik preoperative atau di
kamar operasi.
Antibiotik profilaksis harus diberikan sebelum insisi, jika diindikasikan

Global Guidelines for Prevention SSI; WHO, 2016

 9 Rekomendasi WHO – Preoperatif
Antibiotika profilaksis harus dimasukkan dalam 120 menit
sebelum insisi, dengan mempertimbangkan waktu
paruhnya.

Cuci tangan sebelum operasi dengan sabun antimicrobial

(scrubbing) dan air, atau dengan hand-rub berbasis alcohol
sebelum memakai sarung tangan steril

Cairan antiseptic berbasis alcohol berbasis CHG untuk

persiapan kulit yang akan diinsisi harus digunakan pada
pasien yang akan menjalani pembedahan

Global Guidelines for Prevention SSI; WHO, 2016

 9 Rekomendasi WHO – Preoperatif

Pasien dewasa yang akan dibius secara general anestesi

dengan intubasi endotrakeal harus mendapatkan 80% fraksi
oksigen intraoperatif, dan jika memungkinan pada masa 2-6
jam post operatif.

Antibiotik profilaksis harus dihentikan setelah selesai operasi

Global Guidelines for Prevention SSI; WHO, 2016

 BEBERAPA
REKOMENDASI
BERBASIS
BUKTI UNTUK
PENCEGAHAN
SSI
PREOPERATIVE BATHING
• Disarankan mandi sebelum
operasi (untuk mengurangi
bacterial load pada lokasi
insisi)
• Boleh menggunakan sabun
biasa atau antimikroba
ANTIBIOTIKA PROFILAKSIS

•
 Right Right
Agent Time

Narrowest spectrum of Antimicrobial High Dose, Short time

activity Prophylaxis

Right Right
Duration Dose
Waktu Pemberian Antibiotika Profilaksis
Sebelum Operasi
• Pemberian antibiotika profilaksis sebelum insisi sesuai
indikasi (tergantung jenis operasi)
• Pemberian antibiotika profilaksis dalam 2 jam sebelum
operasi, dengan mempertimbangkan waktu paruhnya
• AB dengan waktu paruh cepat (cefazolin, cefoxitin,
penicillin) diberikan < 60 menit
• AB yg harus diberikan dalam waktu lama (> 1-2 jam) seperti
fluoroquinolone atau vancomycin, harus diberikan > 2 jam
sebelum operasi
• ASHP guidelines merekomendasikan pemberian antibiotika ulang jika
durasi operasi melebihi 2x waktu paruh obat, atau tiap 3-4 jam, atau jika
didapatkan perdarahan >1500 cc
 Durasi

Diteruskan
sampai
Single maksimal
Dose 24 jam post
operasi

Bisa sampai 48 jam pada operasi jantung

 Recommended D-oses, a.nd R:edoslng tor Comm,only Used .Antlml,cm:>bla.ls,tor Sur,glea.l
Intervals IR:0001111111 llos,e Prophylax.ls,
,endesd Half-life i111 Redes iended
Reco111m mg
Adul1s l'l'lf,erval
Alllti Adults.. Witlh Norr11111al
Flu111cti lh (Fmm
micmlbial Rer131
c:m, rr'9 l111itiai1io111 of
Amp icil Ii n-s ul 3g 50 mg/lq;;i of tllo 0.8.-1.3 2P1r,eoperative l!lose),
bactarn {ampicillin 2 gl .amp icil Ii n llilf
sulbactarn 1 component
g)
Ampicilli SO mg/kg 1-1.9 2
n 2g
Aztreonarn 2g JO 1.J.-2.4 4
mg/1,;g
Cofa.zolin 2 g, 3 g for pts 1.2-2.2 4
',,IJili g hin g ~ kg JO
120 mgt,<g
Cofurro:imo SO mg/kg 1-2 4
1.5 g
Cofotaximo SO mg/kg 0.9--1. 3
1 gd 7
Ce,fm:itin 40mg/kg 2
2g 0.7-1. 1
Cofotatan 2g 40mg!kg 2.&-4.6 6
Ceftrmooo 2 g" 50-75mg!kg 5.4-10.9 N
Ciprofruacirt 400mg 10 mgt,<g .3-7 A
Cli ndamycin 900mg 10 mg/kg 2-4 N
E rtapenern 1 g 15mg!kg 3-5 For most pANrAocedures,
cefazolin is the drug of
Fluoonazolt\ 400mg 6mg/l<g .30 choice for6NpA rophylaxis:
Go ntamicin9 5 mg/J< g ba sod
on dosing w.ci g
2.5 mg/kg based on 2-3 • provenNeA fficiency
dosing wai~ht
ht (singlo ooso) • duration of action
ASHP LO'!Jofloxaci
n1
SOOmg
SOOmg
10mg/kg
• spectruNmA of activity
15mg/kg NA
Therapeutic li.lk!,tmnidazol Noonato.s woighing • Safe
o <1200 g should
• low cost
Guidelines recevo a single 7.5-
mg,1,;g dose
llllo:i: 400mg 10mg/kg 8-15 NA
mm:~cin1
P ipc-ra.cil 3.375 lntants 2-9 mo: 80 mg/ 0.7-1.2 2
Ii~ tazobact arn g k g of too p iperaci II in
 For caesarean sections, administer the
appropriate antimicrobial agent prior to skin
incision (versus at cord clamping).

2017 HICPAC–CDC Guidelines for Preventing SSI

 Hair Removal

Hair Removal Infection Rate

Method
sore / kerok/shaving 5.2 - 8.8%
pagi / kerok 6.4 - 10%
sore / cukur 4 - 7.5%
pagi / cukur 1.8 - 3.2%

Alexander JW, et al. Arch Surg 1983; 118:347-352

• Tidak mencukur rambut sama sekali (pre-op atau di OK), atau jika mutlak
diperlukan, hanya boleh dengan clipper.

Clipping hair just before case is best

Current Methods or Hair Removal

- Razor
s
- Depilatories
(seldom seen in Asia)

- Barber
Shears

-Surgical Clippers
 Persiapan Lokasi Insisi

• Preparasi kulit insisi dengan menggunakan cairan antiseptic berbasis alcohol (berbasis
CHG), pada pasien yang akan menjalani pembedahan.
• Meta analisa: alcohol-CHG lebih baik dalam menurunkan risiko SSI dibanding alcohol-
povidone iodine
 Cuci Tangan Sebelum Operasi
• WHO merekomendasikan: scrubbing
menggunakan sabun antimikroba dan air,
atau handrub menggunakan alcohol sebelum
memakai sarung tangan steril.
• Untuk meminimalisasi kontaminasi pada
lapangan operasi, jika ada lubang pada
sarung tangan
• WHO guidelines on hand hygiene in health
care (2009)
Support Nutrisi Preoperatif
• WHO merekomendasikan pemberian suplementasi nutrisi (oral atau
par eneteral) untuk menurunkan risiko SSI pada pasien underweight
yang akan menjalani operasi major.
• Suplemen nutrisi yang mengandung kombinasi arginine, glutamin,
asam lemak omega-3, dan nukleotida.
Oksigenasi Perioperatif
• WHO merekomendasikan pasien yang akan mendapat anestesi
general dengan intubasi endotrakeal harus mendapat oksigenasi 80%
Fi02 intraoperatif, dan jika memungkinkan dalam 2-6 jam pasca
operasi.
J Eval Clin Pract. 2009; 15:360-5.
Elective
Surgical • 500 CRS patients
Procedures • 80% or 30% inspired oxygen during
operation and for 2 hours post surgery
Supplemental
Oxygen • All patients received prophylactic antibiotics

• Results
• Arterial and subcutaneous PO higher in2

80% oxygen group

• Lower incidence of SSIs with higher
supplemental oxygen (5.2% vs 11.2%;
Oxygen Strategy: P=0.01)
•Supplemental O2 for Low O2 2x infection rate
2hrs in RR

Greif et al. N Engl J Med. 2000;342:161–167.

Mempertahankan Normothermia
• WHO merekomendasikan penggunaan bahan/alat penghangat di
kamar operasi dan selama operasi untuk menghangatkan tubuh
pasien, untuk mengurangi risiko SSI.
• Pertahankan suhu tubuh normal selama operasi (1A)
• Keuntungan lain: menurunkan risiko kejadian myokard, kehilangan
darah, dan kebutuhan transfusi.
• Target suhu badan core > 36oC
Elective • 200 CRS patients
Surgical • Control: Routine intraoperative
thermal care
Procedures (mean temperature 34.7°C)
Perioperative • Treatment: Active warming
Normothermia (mean temperature 36.6°C)

• Incidence of SSI
• Control 19% (18/96)
• Treatment 6% (6/104); P=0.009
Warm Patient Strategies: cold patients
•Start with warm room
•Use Blanket had 3x infection
•Cool room for procedure rate
•Use warm iv fluid and
irrigation
•Warm room on closing
GOAL : >36oC (98.6oF)
Kurz A et al. N Engl J Med. 1996;334:1209–1215.
 Kontrol Kadar Gula Darah
• Kadar gula darah harus dikontrol
perioperative, baik pada pasien
dengan DM atau tidak,yang akan
menjalani operasi, untuk
menurunkan risiko SSI.

• Target kadar glukosa perioperatif

< 200mg/dl (1A)
TABLE 1. SUMMARY OF UPDATEO, KEY RECOMMENDATIONS FROM THE CENTERS FOR GU FO TH
DISEASE CONTROL AND PREVENTION DELINE R E
PREVENTION OF SURGICAL SITE INFECTION, 2017
• - .
PARENTERAL ANTIMICROBIAL PROPHYLAXIS
Administer antimicrobials only \Nhen Indicated based on published guidelines. Category 1
8
Time administration such that bactericidal concentration Is established In
serum
For
and caesarean sections,
tissues at Initial administer the appropriate agent prior to skin
Incision. Category IA
(versus at cord clomping). Incision
NONPARENTERAL ANTIMICROBIAL PROPHYLAXIS
Consider use of trlclosan-coated sutlJ'es. Category II
GLYCEMIC CONTROL
Implement porloporatlve glycemlc using blood glucose target levels s 200 Ca1egory IA
control panents.
mg/dl In both diabetic and non-diabetic
NORMOTHERMIA Category IA
Maintain porloporatlve normothermla
OXYGENATION
Administer Increased fraction of oxygen lntraoperatlvely and In the Category IA
Inspired
Immediate post-operative period following extubation for all patients with normal
pulmonary function undergoing general anesthesia with endotracheal
Intubation.
ANTISEPTIC PROPHYLAXIS
Instruct patients to perform full body shower or bath the night before surgery Category 1
(with 8
either soap or an antiseptic agent). Category 1A 2017 HICPAC –CDC
lntraoperatlve skin preparation should be performed with an antiseptic Guidelines for
agent containing alcohol unless contraindicated. Category II Preventing SSI
Consider lntraoperatlve Irrigation of deep or subcutaneous tissues with
2017 HICPAC –CDC Guidelines for Preventing SSI
• Bsc h10 hematom subkutis, kultur?
• Cefazolin 2g