Interpretation of the NHSN surgical site infection definition for sternotomy infections

[John Ferguson]

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
[cid:image001.jpg@01CEB86A.85790C70]

[cid:image002.png@01CEB86A.85790C70][cid:image003.png@01CEB86A.85790C70]

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

[Marija Juraja]

Hi John,

Yes the world of SSIs are changing.

As the surgeon opened the wound and instituted a vac dressing ( a newer, slower and less invasive procedure than surgical debridement including a cleaner closure and surgical wound edge), I would classify go with a deep wound infection.

When we undertake SSI review on a daily basis: we look at several criteria including what other clinical symptoms did the they have including antibiotic treatment before the wound cultures were taken, have they used the correct technique in getting the specimen. Did the anti-thrombolytic agents contribute to the ooze?

John we have mainly implants i.e. joint replacements and we would use the criteria above to determine if they have a SSI. Many times there are no swabs or tissue samples or they are discarded and not sent, but the clinical picture, the invasive procedure and the treatment by the surgeon are all indicators of an SSI.

My thoughts.

Kind Regards

Marija Juraja |Clinical Service Coordinator (CICP) – Infection Prevention & Control Unit|
t: +61 8 8222 7588| p:47757| f: +61 8 8222 6461 | DX: 465432 |e:marija.juraja@health.sa.gov.au

Care Excellence Collaboration Integrity
GERMS CAN KILL…

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
[cid:image001.jpg@01CEB86A.85790C70]

[cid:image002.png@01CEB86A.85790C70][cid:image003.png@01CEB86A.85790C70]
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

[Glenys Harrington]

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

infexion@ozemail.com.au

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

[John Ferguson]

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

[cid:image002.jpg@01CEB910.B1B99D30]

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

[cid:image003.jpg@01CEB90F.65088BF0]

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
infexion@ozemail.com.au
ABN 47533508426

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
[cid:image001.jpg@01CEB86A.85790C70]

[cid:image002.png@01CEB86A.85790C70][cid:image003.png@01CEB86A.85790C70]
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

[Author]

Posts