Surgical site infection

Recommendations

Identify and Treat the Cause
1 Take a careful history and conduct an inspection to identify and modify potential infection sources. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
2 Provide individualized education to patients about incision care. Level of Evidence
5


Provide Local Wound Care
3 Assess and document the status of the incision. Level of Evidence
Not Assessed
4 Optimize the wound healing environment. Level of Evidence
Not Assessed


Provide Organizational Support
5 Determine rates of surgical site infection by appropriate category, such as patient and surgery type, floor, etc., and review current preventive approaches. Level of Evidence
Not Assessed
6 Identify areas for improvement, develop additional protocols as necessary, and implement ongoing staff education. Level of Evidence
Not Assessed
7 Monitor surgical infection rates and adherence to prevention strategies routinely. Level of Evidence
Not Assessed


Background

Despite ongoing prevention efforts, surgical site infections (SSIs) account for approximately 40% of hospital-acquired infections among surgical patients. Approximately 3% of surgical patients develop an infection postoperatively. These infections increase length of hospital stay and associated costs, significantly increase risk of ICU admission, and double the risk of mortality compared with surgical patients who do not develop an infection. SSI is a key surgical outcome indicator.

SSI surveillance is an important tool to identify quality of care and areas of improvement for surgical services. As hospital stays have decreased in length, some of this surveillance must be conducted after discharge. Such surveillance may include telephone contact with patients, distribution of questionnaires to patients and surgeons, and follow-up with physicians diagnosing SSIs.

The major source of infection is the patient’s normal flora entering the body through the incision, although contamination from the surgical environment also contributes. Factors increasing the risk of developing an SSI include diabetes, smoking, perioperative blood transfusion, corticosteroid use and preoperative hospitalization and colonization with Staphylococcus aureus.

Standardized criteria from the Centers for Disease Control (CDC) describe SSI categories:
• Superficial incisional infection: Develops within 30 days of the surgical procedure and involves skin or subcutaneous tissue of the incision
• Deep incisional infection: Develops within 30 days of the surgical procedure or within 1 year of implant placement and involves deep soft tissues of the incision
• Infection of organ or space: Develops within 30 days of the surgical procedure or, if implant is in place, within 1 year and involves any part of the anatomy that was manipulated or opened during surgery, except for the incision.

It is estimated that approximately half of SSIs can be prevented. The Institute for Healthcare Improvement (IHI) recommends the following evidence-based approaches to reduce the incidence of SSIs:

• Give the correct perioperative antibiotics appropriately at the appropriate time. Prophylactic antibiotic use is determined by the type of surgical wound (CDC classification):
o Class I: Clean, uninfected wounds without inflammation, closed by primary intention, which do not enter the respiratory, alimentary, genital or uninfected urinary tract
o Class II: Clean-contaminated wounds, which involve entry to respiratory, alimentary, genital or urinary tract under controlled conditions without unusual contamination
o Class III: Contaminated wounds, including fresh open accidental wounds, surgery with major breaks of sterile technique or gross spillage from gastrointestinal tract, and incisions with visible acute nonpurulent infection
o Class IV: Dirty-infected wounds, including old traumatic wounds with necrotic tissue, wounds with perforated viscera, and those with existing infection.

Prophylactic antibiotics should generally be given within 1 hour before incision to provide bactericidal blood and tissue levels (vancomycin, within 2 hours). Contaminated or dirty wounds usually require a therapeutic course of antibiotics.
Among elderly patients undergoing general surgery, a case-control study found the use of prophylactic antibiotics reduced the risk of 60-day mortality by half.

• Remove hair appropriately. The CDC recommends hair not be removed unless it interferes with the surgery, and then removed with electric clippers, rather than shavers or depilatories. Shaving creates microscopic cuts that increase SSI risk and depilatories may cause hypersensitivity reactions. Development of hair removal protocols and removal of razors from the hospital may be helpful.

• Maintain postoperative blood glucose control in major cardiac surgery patients. Hyperglycemia increases SSI risk, and glucose control decreases mortality in critically ill patients with diabetes. The degree of hyperglycemia can be correlated with the SSI risk for sternal wounds and cardiac surgery. Preoperative screening for diabetes, staff education and a perioperative glucose control or insulin infusion protocol may be useful.

• Maintain normothermia in colorectal surgery patients. Hypothermia (<36º C) during surgery increases the risk of SSIs. In colorectal surgery, hypothermia triples the incidence of SSIs. Various strategies can prevent hypothermia, including using warmed intravenous fluids, increasing the temperature in the operating room, and using active external warming devices.

Other promising interventions include the following:
• Having the patient bathe or shower with an antimicrobial soap preoperatively to reduce epidermal colonization
• Ensuring appropriate operating room standards for ventilation, cleaning and disinfection and monitoring adherence to the standards
• Increasing oxygen tension at the incision site by providing supplemental perioperative oxygen, including for 2 hours postoperatively
• Covering the incision for 24 to 48 hours with a non-adherent sterile dressing: fibrin seals a surgical incision within 24 hours
• Maintaining meticulous hand hygiene before and after dressing changes, contact with the incision and with other parts of the patient’s body
• Using sterile gloves and techniques for dressing changes
• Individualizing patient education before discharge, about caring for the incision, identifying an infection, and knowing when to call the physician.

References

Essential Publications
1 Antisepsis – Preoperative bathing or showering Quality Indicator
 Type: Systematic review
Webster J, Osborne S. Meta-Analysis of Preoperative Antiseptic Bathing in the Prevention of Surgical Site Infection. British Journal of Surgery 2006;93(11):1335-41.
This comprehensive review addresses a specific, focused question and is of high methodological quality. It examines the effectiveness of preoperative bathing with an antiseptic in the prevention of surgical site infections. No evidence was found supporting antiseptic bathing as a means of reducing the incidence of infection.
2 Antisepsis – Preoperative bathing or showering Quality Indicator
 Type: Systematic review
Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004985. DOI: 10.1002/14651858.CD004985.pub3.
This review addresses preoperative procedures to help prevent surgical infections. In a review of over ten thousand patients, it was found that, while bathing or showering was helpful in reducing risk of infection, the benefit of antiseptics over other wash products was questionable.
3 Antisepsis – Preoperative skin antiseptics Quality Indicator
 Type: Systematic review
Edwards PS, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003949. DOI: 10.1002/14651858.CD003949.pub2.
Preoperative skin antisepsis is believed to help prevent postoperative wound infections, but this review was unable to confirm this. The varying results from the studies included in this review prevented a cohesive conclusion from being made. More high quality studies are needed.
4 Antisepsis – Surgical hand antisepsis Quality Indicator
 Type: Systematic review
Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004288. DOI: 10.1002/14651858.CD004288.pub2.
The purpose of this paper was to determine the effect of surgical hand antisepsis on the incidence of surgical site infections and the number of bacterial colony forming units on the surgical team’s hands. Only one randomised controlled trial was found that measured occurrence of surgical site infections, and it showed that there was no difference between alcohol rubs containing additional active ingredients and aqueous scrubs. It was difficult to compare the colony forming unit results from the different randomised controlled trials because each study presented a different comparison, and results were mixed.
5 Post-discharge surveillance Quality Indicator
 Type: Systematic review
Petherick ES, Dalton JE, Moore PJ, Cullum N. Methods for Identifying Surgical Wound Infection After Discharge from Hospital: A Systematic Review. BMC Infectious Diseases 2006: Art No.: 170. ate of Pubaton: 27 NO 2006.
Many surgical site infections develop outside of the hospital setting. This study identified the need for reliable post-discharge surveillance programs to control surgical site infections that do occur. The review found that a valid method has not been developed, and that further research is needed to devise one.
6 Prevention – Disposable surgical face masks Quality Indicator
 Type: Systematic review
Lipp A, Edwards P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002929. DOI: 10.1002/14651858.CD002929.
This systematic review evaluated the role of surgical face masks in the prevention of surgical site infections. Only two randomized controlled trials were found, and they produced conflicting results. More research needs to be conducted on this topic that could potentially have important implications on surgery.
7 Prevention – Double gloving Quality Indicator
 Type: Systematic review
Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003087. DOI: 10.1002/14651858.CD003087.pub2.
In this systematic review the effects of different types of gloves, in particular double gloves, as a precautionary measure in the operating room to reduce the risk of surgical site infections were studied. There was no direct evidence supporting the reduction of surgical site infections when the surgical team wore additional glove protection. More research is needed on this topic.
8 Prevention – Incision barrier Quality Indicator
 Type: Systematic review
Ozer MT, Yigit T, Uzar AI, Eryilmaz M, Kozak O, Cetiner S, Arslan I, Tufan T. Can incision barrier decrease the risk of surgical site infection after appendectomy? Saudi Med J, 2006;27(8):1259-1261.
In this study, the use of an incision barrier, a device inserted into a surgical incision that protects the wound from contamination, was examined. Surgical site infection rate was higher when an incision barrier was not used, but the study was poorly randomized and had a limited population that only consisted of men aged 20 to 44.
9 Prevention – Nail polish and finger rings Quality Indicator
 Type: Systematic review
Arrowsmith VA, Maunder JA, Sargent RJ, Taylor R. Removal of nail polish and finger rings to prevent surgical infection. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD003325. DOI: 10.1002/14651858.CD003325.
In this systematic review, the effect of nail polish and finger rings worn by the surgical team on the incidence of surgical site infections in the patient was investigated. The premise was that bacteria are harboured in nail polish and under rings, and cause infection in surgical patients. There have been virtually no studies on this topic, with the researchers finding only one small randomized controlled trial that indicated that wearing nail polish, both freshly applied and old, had no significant difference in the number of bacteria on the hands compared to not wearing nail polish. Further research is needed and could potentially alter operating room standards.
10 Prevention – Preoperative hair removal Quality Indicator
 Type: Systematic review
Tanner J,Woodings D,Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3.
A longstanding belief is that removing body hair from the surgical site reduces the risk of surgical site infection. This systematic review challenges this traditional belief by examining whether preoperative hair removal is superior to no hair removal in preventing infection. Evidence shows that the difference between the two methods in reducing infection is non-significant.
11 Prevention – Preoperative hair removal Quality Indicator
 Type: RCT
Celik SE, Kara A. Does shaving the incision site increase the infection rate after spinal surgery? Spine 2007;32(15):1575-1577.
This study of 789 spinal surgery patients examines whether presurgical shaving of the incision site has any effect on infection rate. The postsurgical infection rate in the nonshaved group was lower than in the shaved group. This difference was statistically significant, indicating that not shaving may reduce the incidence of infection.
12 Prophylactic antibiotics - Administration - Colorectal Cancer Surgery Quality Indicator
 Type: RCT
Kobayashi M, Mohri Y, Tonouchi H, Miki C, Nakai K, Kusunoki M, Mie Surgical Infection Research Group. Randomized clinical trial comparing intravenous antimicrobial prophylaxis alone with oral and intravenous antimicrobial prophylaxis for the prevention of a surgical site infection in colorectal cancer surgery. Surg Today 2007;37(5):383-388.
This study achieves its objective of showing that intravenous antimicrobial prophylaxis is not inferior to a combination of oral and intravenous treatment.
13 Prophylactic antibiotics – Breast cancer surgery Quality Indicator
 Type: Systematic review
Cunningham M, Bunn F, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005360. DOI: 10.1002/14651858.CD005360.pub2.
Breast cancer surgery has a higher than average risk of infection for clean surgery. In this review, prophylactic antibiotics significantly reduced the risk of infection for these patients. More research is needed to determine which antibiotic is best suited for this particular situation.
14 Prophylactic antibiotics – Breast cancer surgery Quality Indicator
 Type: Systematic review
Tejirian T, DiFronzo LA, Haigh PI. Antibiotic Prophylaxis for Preventing Wound Infection After Breast Surgery: A Systematic Review and Metaanalysis. Journal of the American College of Surgeons 2006;203(5):729-34.
The incidence of infection in breast surgery ranges from 3% to 30%, which is much higher than the accepted rate of 1.5% for clean operations. In this systematic review, prophylactic antibiotics reduced postoperative wound infections in breast surgery with little to no adverse reactions.
15 Prophylactic antibiotics - Ceftriaxone Quality Indicator
 Type: Systematic review
Esposito S, Noviello S, Vanasia A, Venturino P. Ceftriaxone Versus Other Antibiotics for Surgical Prophylaxis : A Meta-Analysis. Clinical drug investigation 2004;24(1):29-39.
The purpose of this well conducted and well written systematic review was to evaluate the effectiveness of the prophylactic antibiotic ceftriaxone in preventing both local and remote postoperative infections. Ceftriaxone was shown to be superior to other antibiotics in preventing infection.
16 Prophylactic antibiotics – Cesarean section Quality Indicator
 Type: Systematic review
Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD000933. DOI: 10.1002/14651858.CD000933.
Cesarean section poses a high risk for postpartum maternal infection. This study looked at the effect of antibiotic prophylaxis, usually administered intravenously but can be orally administered, on reducing the risk of infection. The review found that the administration of antibiotics, regardless of signs of infection, is very beneficial in preventing infection.
17 Prophylactic antibiotics - Dosage - Gastric Cancer Surgery Quality Indicator
 Type: RCT
Mohri Y, Tonouchi H, Kobayashi M, Nakai K, Kusunoki M, Mie Surgical Infection Research Group. Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery. Br J Surg 2007;94(6):683-688.
The purpose of this study was to compare the effects of a single-dose against a multiple-dose treatment plan of prophylactic antibiotics in preventing surgical site infections in gastric cancer surgery patients. The difference was not significant, indicating that a single-dose regimen of antibiotics is just as effective as a multiple-dose regimen at preventing infection.
18 Prophylactic antibiotics – Ear surgery Quality Indicator
 Type: Systematic review
Verschuur HP, Wever WWH de, Benthem PPG van. Antibiotic prophylaxis in clean and clean-contaminated ear surgery. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003996. DOI: 10.1002/14651858.CD003996.pub2.
The purpose of this well-conducted systematic review was to assess the effectiveness of local and/or systemic antibiotics in preventing post-operative complications in patients undergoing clean or clean-contaminated ear surgery. There is no evidence that they were useful in reducing wound infection, discharge from the outer ear canal, labyrinthitis, graft failure, adverse reaction to antibiotic, length of hospital stay or re-operation due to infection. Clinicians will need to make experience informed decisions about using antibiotics to prevent post-operative complications.
19 Prophylactic antibiotics – Gentamicin-collagen - Anal fistula flap Quality Indicator
 Type: RCT
Gustafsson UM, Graf W. Randomized clinical trial of local gentamicin-collagen treatment in advancement flap repair for anal fistula. Br J Surg 2006;93(10):1202-1207.
Anal fistula has a high recurrence rate, and this may be due to infection. The purpose of this paper was to determine if gentamicin-collagen improves healing of anal fistula after endoanal advancement flap repair is performed. This study establishes that the local antibiotic gentamicin-collagen does not improve healing.
20 Prophylactic antibiotics - Mupirocin - Staph arriers- cardiac surgery Quality Indicator
 Type: RCT
Konvalinka A, Errett L, Fong IW. Impact of treating Staphylococcus aureus nasal carriers on wound infections in cardiac surgery. J Hosp Infect 2006;64(2):162-168.
This well designed study that showed the effect of mupirocin on clearing nasal colonies of S. aureus. The researchers hypothesized that clearing S. aureus would help reduce the incidence of post-surgical infection. Although significantly more mupirocin patients cleared S. aureus compared to the placebo group, there was no significant difference in infection rates.
21 Prophylactic antibiotics – Oncological surgery Quality Indicator
 Type: RCT
Skitareli N, Morovi M, Manestar D. Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery. J Craniomaxillofac Surg 2007;35(1):15-20.
The purpose of this paper was to examine the efficacy of two different prophylactic antibiotics, amoxicillin-clavulanate and cefazolin, in preventing infection in oncological surgery. The difference in occurrence of infection between the two antibiotics was found to be non-significant, but the surgical procedure performed was not standardized. Researchers found that the type of procedure performed influenced the incidence of postoperative infection, so a study using a standardized surgical procedure may provide a better perspective on the effect and potential differences of the two antibiotics.
22 Prophylactic antibiotics – Orthopedic surgery Quality Indicator
 Type: RCT
Kato D, Maezawa K, Yonezawa I, Iwase Y, Ikeda H, Nozawa M, Kurosawa H. Randomized prospective study on prophylactic antibiotics in clean orthopedic surgery in one ward for 1 year. Journal of Orthopaedic Science 2006;11(1):20-27.
The purpose of this study was to examine the ability of antimicrobial agents on controlling the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and reduce surgical site infections caused by MRSA. The use of sulbactam/ampicillin decreased the isolation rate of MRSA compared to cefazolin, but the rate of infection was not affected by either antibiotic. Unfortunately, the credibility of the findings of this study is compromised by the methodological deficits of the research. The groups were not truly randomized, there was no mention of blinding, and the control group was not standardized.
23 Surgical techniques – Cataract surgery Quality Indicator
 Type: RCT
Parmar P, Salman A, Kaliamurthy J, Prasanth DA, Thomas PA, Jesudasan CA. Anterior chamber contamination during phacoemulsification and manual small-incision cataract surgery. Am J Ophthalmol 2006;141(6):1160-1161.
In this paper, two different surgical techniques, phacoemulsification and manual small-incision cataract surgery, were examined with the goal of reducing infection during cataract surgery. The difference in the incidence of anterior chamber contamination between the two groups was not significant.
24 Wound cleansing – Water Quality Indicator
 Type: Systematic review
Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003861. DOI: 10.1002/14651858.CD003861.pub2.
In this systematic review, various solutions, water in particular, were examined for cleansing wounds. There was no statistically significant evidence that water reduces the risk of infection in treating both acute and chronic wounds. The evidence was also not strong concerning the idea that cleansing wounds in general increased healing or reduced infection. Better-quality and well-designed studies are needed on this topic.
25 Antisepsis – Preoperative showering Quality Indicator
 Type: RCT
Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: A prospective study. Plast. Reconstr. Surg. 2005;116(2):529-531.
The purpose of this study was to determine the efficacy of preoperative showering with antiseptics in preventing wound infections in elective outpatient plastic surgery. 1810 patients were evenly divided into two groups (using a randomization procedure regarded as not appropriate), one showering with normal saline solution and the other showering with the antiseptics Chlorhexidine or Betadine. No surgical site infections occurred in either group. This indicates that preoperative showering with antiseptics does not significantly reduce levels of infection.


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