Course Access
Hi John,
While there is no muscle there is fascia and if involved you would proceed
with using the deep definition to see if you meet the other criteria. From
your description it seems in your cases you would meet b plus 1 signs of
infection confirming it was a deep infection.
The definition seems fairly straight forward to me and I have found it very
easy to use over the years. It is a definition for surveillance purposes
not clinical management.
By definition an organ space infection does not include the wound, hence
infection deep to the deep fascia a deep (or organ space infection) is
not the correct application of the organ space definition.
Vac dressings can be used on lots of wounds including superficial sternal
wounds (see below). The foam is cut and contoured to fit the size of the
tissue defect, and covered with an adhesive drape and connected through the
evacuation tube to the vacuum pump. There is no exposure of the wound
bed/surface using these devices.
From memory there is usually an percutaneous suture in closure of a sternal
wound.
Bapat V et al. Experience with Vacuum-assisted closure
of sternal wound infections following cardiac surgery and evaluation of
chronic complications associated with its use.
J Card Surg. 2008
May-Jun;23(3):227-33Department of Cardiothoracic Surgery, St Thomas’
Hospital, London, UK. vnbapat@yahoo.com
Dezfuli B et al, Treatment of Sternal Wound Infection With Vacuum-assisted
Closure. Wounds. 2013;25(2)
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
ABN 47533508426
Of John Ferguson
site infection definition for sternotomy infections
Thanks Glenys
However, there is no muscle overlaying the sternum and the deep fascia is
just above the periosteum of the sternum.
For the most part there is just skin and subcut tissue in front of the
sternum. These tissues overlying the sternum are very thin in most people.
And so it is nonsensical to distinguish superficial from deep based on this
definition in my view
I don’t think that most surgeons put a closure layer beneath the skin once
the sternum is wired- it is impossible. Effectively, then, opening or
dehiscence of the incision will expose the fascia. Similarly, I cannot see
that application of a vac can be done to a ‘superficial’ wound as the fascia
will be exposed in these sort of wounds.
I could cope if the definition specified in this case that infection deep to
the deep fascia a deep (or organ space infection); however that is not
what it says.
We are long overdue for a better NHSN SSI definition., esp for sternal
wounds
John
Dr John Ferguson
Director, Infection Prevention & Control, Hunter New England Health
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 |
john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org
http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-H
ealth-Hunter-New-England-LHD.jpg
Of Glenys Harrington
for sternotomy infections
Hi John,
Whether or not these wounds are superficial or deep depends on the first
part of the definition as to what tissue is involved. This question has to
be answered before progressing to the rest of the definition.
Superficial – Infection occurs within 30 days after any NHSN operative
procedure and involves only skin and subcutaneous tissue of the incision
Deep – Infection occurs within 30 or 90 days after the NHSN operative
procedure and involves deep soft tissues of the incision (e.g., fascial and
muscle layers)
If only skin and subcutaneous tissue are involved it meets the superficial
definition as from your description c below is met and, Im assuming that
the patient had at least 1 of the sign or symptom below.
patient has at least 1 of the following:
a. purulent drainage from the superficial incision
b. organsims isolated from an aseptically-obtained culture of fluid or
tissue from the superficial incision
c. superficial incision that is deliberately opened by a surgeon and is
culture-positive or not cultured
and
patient has at least one of the following signs or symptoms of infection:
pain or tenderness; localized swelling; redness; or heat. A culture negative
finding does not meet this criterion
d. diagnosis of superficial incisional SSI by the surgeon or attending
physician
If deep soft tissues (e.g., fascial and muscle layers) are involved it will
meet the deep definition as from your description b below has been met and
Im assuming that the patient has at least 1 of the sign or symptom below.
patient has at least one of the following:
a. purulent drainage from the deep incision
b. a deep incision that spontaneously dehisces or is deliberately opened by
a surgeon and is culture- positive or not cultured
and
patient has at least one of the following signs or symptoms: fever (>38C);
localized pain or tenderness. A culture-negative finding does not meet this
criterion.
c. an abscess or other evidence of infection involving the deep incision is
found on direct examination, during invasive procedure, or by
histopathologic examination or imaging test.
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
Hence in the first instance you need to know what level the surgeon has
opened these wounds too as VACs can be used on superficial or deep would
infections.
Just on organ space infections these wounds as described would not be
considered an organ space infection as such infections exclude the skin
incision, fascia, or muscle layers, that is opened or manipulated during the
operative procedure (i.e. the incisional wound is not involved at all). In
this surgical setting an organ space infection would be something like
osteomyelitis of the sternum without surgical incision/wound involvement.
I use a definition checklist (i.e. it either meets or does not meet the
criteria) when training staff in the interpretation of the definitions for
surveillance purposes.
Can send a copy if you like.
Regards
Glenys
Glenys Harrington
Consultant
Infection Control Consultancy (ICC)
PO Box 5202
Middle Park
Victoria, 3206
Australia
H: +61 3 96902216
M: +61 404 816 434
ABN 47533508426
Of John Ferguson
infection definition for sternotomy infections
Dear All
Would appreciate advice on interpretation of the definition (below)
In two sternotomy cases, there has been prolonged ooze post op (several
days) and the surgeon concerned has opened the wound on the ward and then
instituted vac dressings
The cases required prolonged nursing management but did not come to formal
debridement or removal of sternal wires etc. CT scans did not show
retrosternal collections (ie not organ space infection)
In my view, this constitutes a ‘deep’ wound infection. What would others
say?
Our other surgeons would have usually taken such cases to theatre and
performed open debridement
in one case the culture grew Serratia
in the other, culture was no growth; in that case, the determination rests
then on whether we had ‘purulent drainage’ observed from the ‘deep incision’
it does beg the question as to how one gauges from what level the drainage
is coming fron and also whether one should use an objective measure for what
is purulent etc!
criterion b under superficial is also problematic – how does one ever get
‘aseptically-obtained’ samples from a superficial incision? wound swabs
presumably not ok but I would guess are used
Would be very interested to know of how people teach surveillance staff to
apply the NHSN definition, esp for sternotomies , where essentially the
superficial wound is extremely close to the deep sternal structure , and
also for prosthetic joints where similar problems of distinguishing the
depth of infection arise
thanks
John
Dr John Ferguson
Director, Infection Prevention & Control, Hunter New England Health
Locked Bag 1, Newcastle Mail Centre, NSW 2310
Tel 61 2 4921 4444 | Fax 61 2 4921 4440 | Mob +61 428 885 573 |
john.ferguson@hnehealth.nsw.gov.au | http://www.hicsiganz.org
http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-H
ealth-Hunter-New-England-LHD.jpg
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.
Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to
aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without
the quotes) to listserv@aicalist.org.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.
Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to
aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without
the quotes) to listserv@aicalist.org.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO
NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is
discouraged by ACIPC. If you wish to discuss specific reference to products
or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives –
registration and login required.
Replies to this message will be directed back to the list. To create a new
message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to
aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without
the quotes) to listserv@aicalist.org.au
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
Archive of all messages are available at http://aicalist.org.au/archives – registration and login required.
Replies to this message will be directed back to the list. To create a new message send an email to aicalist@aicalist.org.au
To send a message to the list administrator send an email to aicalist-request@aicalist.org.au.
You can unsubscribe from this list be sending ‘signoff aicalist’ (without the quotes) to listserv@aicalist.org.au