Classification of surgical wound and their antimicrobial prophylaxis:

Surgical Wound Classification

Antimicrobial prophylaxis

Class I/Clean:


An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in this category if they meet the criteria.

 None or single perioperative dose of cefuroxime/ cefazolin

Class II/ Clean-Contaminated:


An operative wound in which the respiratory, alimentary, genital or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.

Cefazolin or Ampicillin-sulbactam or Ceftriaxone or

(Limited to patients requiring antimicrobial treatment for acute cholecystitis or acute biliary tract infections which may not be determined prior to incision. Factors that indicate a high risk of infectious complications in laparoscopic cholecystectomy include emergency procedures, diabetes, long procedure duration, intraoperative gallbladder rupture, age of >70 years, conversion from laparoscopic to open cholecystectomy, American Society of Anesthesiologists classification of 3 or greater, episode of colic within 30 days before the procedure, re-intervention in less than one month for noninfectious complication, acute cholecystitis, bile spillage, jaundice, pregnancy, nonfunctioning gallbladder, immunosuppression) Clindamycin or Vancomycin For procedures in which pathogens other than staphylococci and streptococci are likely, an additional agent with activity against those pathogens could be considered. For example, if there is surveillance data showing that gram-negative organisms are a cause of surgical-site infections (SSIs) for the procedure, practitioners may consider combining clindamycin or vancomycin with another agent like cefazolin, aztreonam, gentamicin, or single-dose fluoroquinolone if the patient is β-lactam allergic).

Class III/Contaminated:


Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered are included in this category.

 Cefuroxime + Metronidazole
Metronidazole+Aminoglycoside/
Fluoroquinolone

Class IV/Dirty-Infected:


Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.

 Cefazolin + metronidazole, cefoxitin, cefotetan, ampicillin–sulbactam, ceftriaxone + metronidazole, ertapenem Clindamycin + aminoglycoside or aztreonam or fluoroquinolone + metronidazole

In the ICMR’s surveillance data, 39% of the 12,336 isolates from out-patients and 32% of the isolates from ward were from pus samples. Gram negative pathogens accounted for 76% isolates from the surgical site and 62% from pus, which should have an important bearing which framing treatment guidelines, especially, since most guidelines target S. aureus.The overall rate of MRSA was 32% for the year 2017. The commonest species of CONS were S. haemolyticus and S. epidermidis, the former had MR rate of 86.6% & the latter 61%.

The profile of surgical site isolates in the ICMR surveillance data is as under:

- Enterobacteriaceae - 73.2%

    OPD - 11.6 %
    IPD - 68.6 %
    ICU - 19.8 %
    Citrobacter - 1.3%

- Enterococcus species - 10.9%

- Non- fermenting gram-negative bacilli - 8.2%

- Staphylococcus aureus - 0.9%

Organisms

    Enterobacteriaceae – 46.20%
    Salmonella – 0.3%
    NFGNB – 27.4%
    Staphylococcus – 7%
    Enterococcus – 16.8%
    Fungi – 0.8%
    Faceal pathogens– 1.5%

Pus samples

    OPD – 33.2%
    Wards – 57.4%
    ICU – 9.3%

Organisms

    Enterobacteriaceae– 38.3%
    Salmonella – 0.1%
    NFGNB – 23.7%
    Staphylococcus – 33.3%
    Enterococcus – 44%
    Fungi – 0.2%
    Faecal pathogens – 0%