alenc uiv e & eq B io io B a Tariq et al., J Bioequiv Availab 2017, 9:1 f v o a i l l a a b DOI: 10.4172/jbb.1000321 n r i l i u t y o J Journal of Bioequivalence & Bioavailability ISSN: 0975-0851 Review Article Open Access A Systemic Review on Surgical Site Infections: Classification, Risk Factors, Treatment Complexities, Economical and Clinical Scenarios Tariq A1, Ali H2, Zafar F3, Sial AA1, Hameed K4, Naveed S5*, Shafiq Y1, Salim S4, Mallick N1 and Hasnain H1 1Department of Pharmacy, Ziauddin University, Karachi, Pakistan 2Department of Pharmacy, Jinnah Sindh Medical University, Karachi, Pakistan 3Department of Pharmacy, University of Karachi, Karachi, Pakistan 4Department of Medicine, Ziauddin University, Karachi, Pakistan 5Jinnah University for Woman Karachi, Karachi 74600, Pakistan Abstract Objective: To signify the risk factors, treatment complexities, economical and clinical scenarios related to Surgical Site infection (SSIs). The second most common health care associated infection is the Surgical Site infection, which may increase morbidity and mortality rate among surgical patient and produce a greater influence on length of stay during hospitalization, readmission and economic cost. Method: A methodical literature investigation was conducted to recognize the extent of studies in relation to SSI. Procedural details of SSI, quality attributes in term of various components of SSI were assessed. Results: The incident rate reported in different countries shows divergent variation because of the numerous systems integrated in the epidemiological control of Hospital acquired Infection. Staphylococcus aureus is most frequent pathogen associated with SSI. Increased treatment cost is mostly associated with additional length of hospitalization and supplementary diagnostic testing’s, extra medication/antibiotic utilization and maybe any other minor surgical procedure in certain conditions. Conclusion: This Literature review elaborates the risk factors, classification, economical and clinical scenario and also demonstrates the treatment challenges in various perspectives. Keywords: Surgical site infections; Economic cost; Prophylaxis Classification of SSIs antibiotic; Multi factorial risk; Epidemiological control Surgical Site infection is categorized into three different types Introduction according to The Centers for Disease Control and Prevention (CDC's) and National Nosocomial Infections Surveillance System (NNIS) Health Care-Associated Infections (HAIs) remain as an important characterized by Superficial incision which include only the skin public health concern. Amongst the prominent HAIs, Surgical Site and subcutaneous tissue, whereas Deep incision in which infection Infections (SSIs) contributing to substantial rate of mortality, significant penetrate in deep tissue, such as facial and layer of muscle; It also morbidity, considerable prolongation in length of hospitalization and includes infections which involve both superficial and deep incision added treatment expenses. Despite the technical advancements that sites, organ/space SSI drainage through incision. While organ/space have been practiced over the past few years in surgical and wound defined as an infection in any organ or space other than the incision site management system, wound infections are still viewed as the most [10]. Literature Survey conducted by Isik et al. reports the incident rate widely recognized nosocomial infections, particularly in patients in superficial incision is found to be 42.19%, which is more frequent, experiencing surgery. SSIs were estimated approx. 31% of all HAIs, followed next in frequency by deep incision having an SSI 40.1% while which contributed 20% postsurgical readmissions as well [1-2]. Over organ space shows 17.71% rate of infection [11]. the years, the amplified interest of various investigators for surgical In 1964 National Research Council group (United States) categorize infection has generated various guidelines for control of post-surgical post-surgical lesion (wound) in four major categories considering the infection. But still In the United States, 14-16% of estimated 2 million degree of microbiological contagion (Table 1) [12]. However, recently of Nosocomial infections, which affects hospitalized patients; develop the contaminated and dirty wound infections are conjointly classified SSI. The rate of SSIs is reported in numerous literatures in the range of 2.5-41.9% [3-6]. The patients of SSIs have 2-11 times greater risk of death as compared to the patients having no SSI [7]. The number of *Corresponding author: Safila Naveed, B. Pharm., M. Phil., Ph. D., R. Ph., incidences reported for SSI may be different across several countries Associate Professor, Faculty of Pharmacy, Jinnah University for Women, Karachi 74600, Pakistan, Tel: 00923002621917; E-mail: [email protected] due to the various systems applied for the epidemiological control of Received August 27, 2016; Accepted December 29, 2016; Published January hospital related infection. Surgical Wound Infection Task Force USA 12, 2017 published a standardized application for the SSI in 1992 which includes Citation: Tariq A, Ali H, Zafar F, Sial AA, Hameed K, et al. (2017) A Systemic “the existence of purulent drainage; impulsive drainage of fluid, apart Review on Surgical Site Infections: Classification, Risk Factors, Treatment from the culture sensitivity for specific bacterial specie; localized Complexities, Economical and Clinical Scenarios. J Bioequiv Availab 9: 336-340. symbols of contagion for outward sites or radiological verification of doi: 10.4172/jbb.1000321 infections from deep sites; an eruption/abscess or additional infection Copyright: © 2017 Tariq A, et al. This is an open-access article distributed under of direct surgical procedure; or an identification of an infection by a the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and surgeon [8-9]. source are credited. J Bioequiv Availab, an open access journal ISSN: 0975-0851 Volume 9(1): 336-340 (2017) - 336 Citation: Tariq A, Ali H, Zafar F, Sial AA, Hameed K, et al. (2017) A Systemic Review on Surgical Site Infections: Classification, Risk Factors, Treatment Complexities, Economical and Clinical Scenarios. J Bioequiv Availab 9: 336-340. doi: 10.4172/jbb.1000321 Definition/Major Characteristics of Respective Literature reported in Pakistan illustrates the incidence rate of Wound Type Class Classes SSI may be outdated because various factors influences the infection No inflammation stumbles upon and the rate For instance, Ahmed et al. conducted a study in Surgical Unit, gastrointestinal (GI), respiratory, genital & urinary showed that the incidence rate of SSI was 11% [16]. While Khan et al. Clean I tract is not involved. Discretionary (elective), not emergency, principally closed and without rupture/ reported in their study that the infection rate was found to be 9.294% break techniques involved. [9]. Globally, the incident rate of SSI is 2.6% documented in the USA, Operative method involved a colonized viscera or Tanzania reports 19.4% of cases, multi-center Italian study shows 2.7% cavity (opening) of the body, although with controlled Clean- SSI, while the Belgian study documented 1.47% cases of SSI [17]. II and elective situations with nominal spillage. contaminated Furthermore, emergency and urgent cases are clean Risk factors related to SSI otherwise, inconsequential break in technique. Operative procedures are carried out with major In various investigational studies, based on routine examination of interruption/breaks in desolate/aseptic/sterile method multiple clinical scenarios, a wider magnitude of risk factors and their (like open cardiac massage) or gross/foul spillage/ drain from the GI tract, access into genitourinary burden related to the occurrence of SSI can be evaluated. Such studies Contaminated III or biliary system in the existence of contaminated have focused multi variant patient groups, in relation to the particular bile/urine contents and incisions with non-purulent, type of risk factors within various clinical trials [18]. Two models sensitive and acute inflammation are integrated into this group. including Efficacy of the National Nosocomial Infections Surveillance Dirty wounds are demonstrated with surgical (NNIS) index and the Nosocomial Infection Control (SENIC) index Dirty IV processes mainly involved active infections prior to were developed to control the strategies and reduce the morbidity and surgery. mortality rates in consequence of post-surgical infection. Table 1: Classification of wounds [14]. Multi factorial risk coupled with SSI in which Patient correlated as “dirty wounds” [9]. Furthermore, Class I is used as a useful indicator factors include diabetes mellitus, obesity, anemia, immune-suppressant for the referral in case of hospital associated problems [13]. drugs, use of corticosteroids, malnutrition [19]. Similarly, other factors include the duration of surgery, poor postoperative glycemic control; Rationale of Clinical Implications and Complexities prolong post-operative stay, duration of surgery, different type of Associated with SSI surgery, preoperative stay and surgery techniques employed. Infection at remote sites, preoperative temperature and presence of drains also Surgical procedures create widespread challenges due to its key elements in the progress of SSI [20-21]. Literature survey shows that undesirable events related