Surgical site infections

What is the impact of surgical site infections?

Approximately 27 million surgical procedures are performed in the United States each year, with up to 5% resulting in surgical site infections (SSI). Trends in the incidence of SSI are monitored by the National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC). According to NNIS data, SSIs are the third most frequently reported nosocomial infection and are associated with substantial morbidity that can endanger a patient’s life, increase the number of days in the hospital, and increase healthcare costs. This chapter describes the types of SSI, lists risk factors, and explains prevention strategies.

What are surgical site infections?

Surgical site infections are defined as infections that occur 30 days after surgery with no implant, or within 1 year if an implant is placed and infection appears to be related to surgery. Infections are classified as either incisional or organ/space infections to differentiate those that occur at the incision site from those related to the organ or space manipulated during surgery. Incisional infections are further classified as superficial or deep.

Characteristics of SSIs are summarized in Table I.

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What is the incidence of surgical site infections?

In the United States, the incidence of SSI is tracked by the National Nosocomial Infections Surveillance (NNIS) system and the National Hospital Discharge Survey, both sponsored by the CDC. The American Hospital Association also compiles statistics through an annual survey. A study by Klevens RM et al using all of these data sources determined that 244,385 SSIs were reported in U.S. hospitals in 2002, accounting for 20% of all healthcare-associated infections and nearly 2% of all monitored surgical procedures.

What are the consequences of surgical site infections?

Surgical site infections are associated with substantial morbidity and mortality. Patients with SSI are twice as likely to die, 60% more likely to be admitted to the intensive care unit, and more than five times more likely to be readmitted to the hospital after discharge. In 2002, SSIs contributed to 8205 deaths. Occurrence of SSI is estimated to increase hospital stay by 7 to 10 days and add over $3,000 in costs of care. In a comparison study (Kirkland KB, 1999) of surgical patients with vs. without infection, the median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. Patients who were readmitted after discharge incurred higher costs of over $5,000.

Higher costs of care were reported in a 2009 study by a CDC economist (Scott RD), who estimated the cost of treating SSI at $10,443 to $25,546. At a rate of 5 SSIs per 100 surgical procedures, the total annual cost of treating SSIs was projected at $3.2 to $10 billion. These wide variations in cost of care reflect the complex nature of SSIs, which may substantially differ in severity depending on the causative pathogen, type of surgical procedure performed, patient’s underlying health condition, and other factors.

What is the microbiology of surgical site infections?

Surgical site infections may be caused by endogenous or exogenous microorganisms. Most SSIs are caused by endogenous microorganisms present on the patient’s skin when the surgical incision is made. Gram-positive bacteria such as Staphylococcus aureus are the most common causative skin-dwelling microorganisms. Surgical site infections may also be caused by organisms within the patient’s body that are exposed during surgery. Causative pathogens depend on surgical site; for example, the risk of developing SSI from enteric gram-negative microorganisms increases with surgery on the gastrointestinal tract. Exogenous sources of microorganisms include surgical instruments, operating room surfaces, the air, and personnel.

The most common pathogens responsible for SSI are presented in Table II.

How important is the issue of antibiotic resistance in the context of surgical site infections?

The risk of SSI caused by resistant bacteria has become a major concern for hospitals and healthcare professionals. “Resistance” is the term used to describe the ability of a microorganism to withstand the effects of an antimicrobial agent. Microorganisms acquire resistance through evolution and adaptation. In particular, there is concern about the rise in SSIs due to vancomycin-resistant enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), third generation cephalosporin-resistant Escherichia coli, and imipenem- and quinolone-resistant Pseudomonas aeruginosa.

What are the consequences of antibiotic resistance on surgical site infections?

The development of resistant microorganisms can result in increased morbidity, mortality, and costs of care. For example, in one study the presence of MRSA in a surgical incision was associated with a 12-fold increase in 90-day postoperative mortality, compared with uninfected patients. Hospitalization stays for these patients increased a median of 5 days, and median costs of care were nearly $40,000 higher for MRSA-infected patients compared with uninfected patients. Hospitalized patients with VRE had a 6% increased risk of mortality, 6.2 days of excess hospitalization, and $12,766 in additional hospital costs, compared with uninfected patients. Hospital costs attributable to nosocomial infections caused by resistant bacteria have been conservatively estimated at $1.6billion per year in the United States.

Which factors predispose an individual to surgical site infections?

Risk factors for developing SSI can be broadly grouped by patient, wound, and procedural variables. Patient variables that increase risks for SSI include the following:

  • Very young or very old age

  • Diabetes (especially increased HgA1c and glucose ³200 mg/dL within 48 hours after surgery)

  • Tobacco use

  • Steroid use

  • Compromised immune system

  • Infection or colonization at a remote body site

  • Obesity

  • Poor nutritional status

  • Length of preoperative stay (increases exposure to pathogens)

  • Wound contamination

What is the relationship between wound contamination and surgical site infections?

Wound contamination is a significant risk factor for developing SSI. In 1964 a classification system was developed to categorize wounds based on the degree of microbial contamination present. The wound is classified by a member of the surgical team and used as one variable to assess the risk of SSI.

This classification system is presented in Table III.

Which procedural variables affect surgical site infections?

Procedural variables include factors related to preoperative skin preparation, sterilization protocols, and the surgery itself. Procedural variables that can affect the risk for SSI include the following:

  • Antimicrobial prophylaxis

  • Duration of surgical scrub

  • Preoperative hair removal

  • Skin antisepsis protocol

  • Choice of preoperative skin preparation

  • Operating room ventilation

  • Wound class

  • Sterilization of instruments and environment

  • Foreign matter in the surgical site

  • Surgical techniques

  • Duration of surgery

How is the risk of surgical site infections stratified?

Two SSI risk stratification systems have been developed. The Study on the Efficacy of Nosocomial Infection Control (SENIC) project determined that the risk for an SSI increases for patients with the following criteria:

  • Abdominal surgery

  • Operation lasting >2 hours

  • Class III or Class IV wound classification (contaminated or dirty-infected)

  • Surgery performed on a patient with 3 or more discharge diagnoses

The National Nosocomial Infections Surveillance System (NNIS) index assesses higher SSI risk when the following variables are present:

  • Class III or Class IV wound classification (contaminated or dirty-infected)

  • Length of operation > T hours, where T is the 75th percentile of the duration of the specific operation being performed

  • American Society of Anesthesiology (ASA) Physical Status Classification of >2, as follows:

    P1 A normal healthy patient

    P2 A patient with mild systemic disease

    P3 A patient with severe systemic disease

    P4 A patient with severe systemic disease that is a constant threat to life

    P5 A moribund patient who is not expected to survive without the operation

    P6 A declared brain-dead patient whose organs are being removed for donor purposes

How can surgical site infections be prevented?

SSI Prevention Strategies

The most effective SSI prevention strategies involve a multi-faceted approach including protocols exercised before, during, and after surgery to reduce exposure and susceptibility to pathogens. Several infection control guidelines and initiatives are available to serve as a foundation for hospital programs to reduce the incidence of SSI. Guidelines are summarized in the section titled, Initiatives to Reduce SSIs.

Prevention strategies can be categorized as follows:

  • Preoperative patient preparation

    Tobacco cessation

    Antimicrobial prophylaxis

    Preoperative showering

    Hair removal

    Preoperative skin antisepsis

    Preoperative scrubbing

  • Perioperative techniques

    Prevention of intraoperative hypothermia

    Glucose monitoring

    Perioperative hyperoxia

    Incision care

What is the role of tobacco cessation in surgical site infections?

Use of tobacco products has been associated with higher rates of SSI. Nicotine use delays wound healing, and cigarette smoking is an independent risk factor for the development of SSI. For elective procedures, patients should be encouraged to stop using all tobacco products at least 30 days prior to surgery.

How can antimicrobial prophylaxis be optimized?

Antimicrobial Prophylaxis (AMP)

Antimicrobial prophylaxis (AMP) refers to a short course of antimicrobial therapy administered prior to surgery to reduce microbial counts to a level that will not overwhelm host immune response. Antimicrobial prophylaxis should be administered only for Class I and II wounds. Patients with Class III or IV wounds are presumed to be taking antimicrobial therapy already. Optimal AMP therapy requires:

  • Use of the correct agent for the type of operation, based on clinical evidence

    Cephalosporin for coverage of most clean procedures due to its safety, broad-spectrum efficacy and low cost

  • Appropriate timing of administration:

    30 to 60 minutes prior to incision (i.e., enough time to reach bactericidal serum and tissue concentrations); 1-2 hours for antibiotics with longer periods of infusion, such as vancomycin

    Re-administration if surgery is delayed beyond 1 hour after the first AMP dose

    Maintained at therapeutic levels in both serum and tissues throughout surgery

    Lasting no longer than 24 hours after the end of surgery to reduce risk of developing resistance

Is preoperative showering effective for infection control?

The CDC recommends that patients shower preoperatively using an antiseptic to reduce microbial counts on the skin prior to surgical incision. Using chlorhexidine gluconate is associated with a 9-fold reduction in microbial counts on skin. In one study, the SSI rate was lower among patients who showered with chlorhexidine (9%) compared to those who showered with bar soap (12.8%) or placebo (11.7%). The Association of Operating Room Nurses (AORN) recommends that patients undergoing Class I (clean) procedures take two showers with chlorhexidine gluconate 4% solution the night before surgery. For surgeries involving the head, two preoperative shampoos with chlorhexidine gluconate 4% solution are recommended.

Is hair removal an effective method of infection control?

Hair removal was once theorized to reduce the risk of post-operative infection and, accordingly, became routine practice in many operating rooms. In fact, shaving creates small cuts and microabrasions in the skin in which bacteria can collect and multiply and is associated with increased incidence of SSI. Shaving longer than 24 hours prior to surgery is associated with a higher SSI risk than shaving immediately prior to incision. Hair removal using a depilatory is not associated with increased SSI risk but can produce skin irritation. If hair removal is necessary, clipping, rather than shaving, is recommended and should be done immediately prior to surgery.

What constitutes optimal skin antisepsis?

Given the strong correlation between the presence of skin-dwelling microorganisms and infection, it is critical to adequately disinfect the surgical site prior to incision to decrease the risk of SSI. U.S. Food and Drug Administration (FDA) criteria for a recommended antiseptic agent include the following characteristics:

  • significantly reduces microorganisms on the skin

  • contains an antimicrobial agent

  • provides broad-spectrum coverage

  • is fast-acting

  • has a sustained effect

Other considerations in choosing an antiseptic agent include patient allergy or sensitivity to ingredients, surgeon preference, and location of incision. Product label recommendations and warnings should be closely followed. Commonly used skin antiseptics include alcohol, chlorhexidine gluconate, and iodine/iodophors.

Table IV lists characteristics of commonly used agents for surgical antisepsis.

A recent landmark study evaluated the rate of SSI in patients prepped preoperatively either with chlorhexidine gluconate plus alcohol solution or with povidone-iodine. In this randomized, controlled, multicenter trial, 897 patients undergoing clean-contaminated surgery were randomized to have their skin disinfected preoperatively with either 2% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) or 10% povidone-iodine. The primary endpoint was the occurrence of any SSI within 30 days after surgery. The occurrence of individual types of SSI was a secondary endpoint. Surgeons were unblinded, whereas patients and investigators who diagnosed SSI were blinded to the antiseptic product used.

Patients were contacted weekly following discharge, up to 30 days post-procedure. If SSI was diagnosed or suspected, cultures were taken to confirm the presence of microorganisms. The overall rate of infection was significantly lower in patients prepped with CHG/IPA (9.5%) compared to those prepped with povidone-iodine (16.1%, P=0.004). The risk of SSI was reduced 41% for patients prepped with CHG/IPA compared to those whose skin was disinfected with povidone-iodine. There were also significantly fewer superficial incisional and deep incisional infections in the CHG/IPA arm.

What is the impact of preoperative scrubbing on infection control?

In addition to reducing microorganisms on patient skin, all healthcare professionals who have direct contact with patients during surgery should reduce microbial counts on their own skin. Staff who prepare patients for surgery must thoroughly disinfect their hands prior to touching the patient. Similarly, surgical team members must undergo preoperative scrubbing of hands and forearms. Arms and hands should be scrubbed for at least 5 minutes before the first surgery each day, and between 2 to 5 minutes before each subsequent procedure. The antiseptic used as a scrub agent should contain broad-spectrum antimicrobial properties. Scrubs containing chlorhexidine gluconate produce a greater antimicrobial effect than other antiseptics. The addition of alcohol to chlorhexidine gluconate provides more persistent effects than povidone-iodine alone. A study demonstrated that the rubbing with chlorhexidine gluconate and alcohol produced a >50-fold reduction in bacterial counts on the hands, while the use of the comparator, povidone-iodine scrub, resulted in only a 3-fold reduction.

What is the relationship between intraoperative hypothermia and surgical site infections?

Intraoperative hypothermia can contribute to SSI by producing vasoconstriction that reduces blood flow to the incision site and limits delivery of oxygen to the tissue surrounding the wound. In a study that evaluated the effects of hypothermia on SSI rates, 200 patients undergoing colorectal surgery were randomly assigned to routine intraoperative thermal care (the hypothermia group) or additional warming (the normothermia group). Patients in the hypothermia group developed significantly more SSIs post procedure than the normothermia group (19% vs. 6%, respectively). Additionally, the average number of days in the hospital was higher for the hypothermia group compared to the normothermia group. To avoid hypothermia, staff could use blankets, warmed intravenous fluids, or forced air warming to maintain the patient’s core temperature throughout surgery, where feasible.

Are there controversies associated with forced air warming?

A number of devices have been introduced to provide forced air warming to prevent hypothermia. A commonly used system includes a “blanket” attached to a forced air unit. The blanket is designed to distribute warmed air evenly over the portion of the patient’s body. These devices have demonstrated efficacy in preventing hypothermia, which is also associated with improved tissue viability and reduced incidence of bed sores. However, recent reports in the literature question whether inadequately filtered air from the blowers may be contaminated with pathogens, exposing patients to increased risks of infection. Another theory is that forced air may mobilize microorganisms on the patient’s skin. Analysis of bacterial contamination in operating room air and around and on patients’ bodies has not demonstrated increased risks of infection when forced air units are used.

How can surgical site infections be reduced by improving glucose control?

High blood glucose levels are associated with increased risk of SSI, regardless of the presence of diabetes . A study of 647 patients undergoing major non-cardiac surgery showed that post-surgery infections were related to hemoglobin A1c (HbA1c) levels. Specifically, HbA1c levels below 7% were associated with significantly fewer infections following surgery. Among patients with diabetes, several studies suggest that failure to control blood glucose before and after surgery correlates with the development of SSIs. Blood glucose levels should be controlled in patients with diabetes both before and after surgery to reduce SSI risk.

Is hyperoxia a controversial means of infection control?

Surgery disrupts the vascular delivery of oxygen to the wound site, leading to a hypoxic state in wound tissue. Supplemental oxygen has been suggested as a means of improving oxygenation and possibly decreasing the risk for SSI. Studies of supplemental oxygenation have produced contradictory results, however. In a randomized controlled study (Pryor KO et al, 2004) of patients undergoing abdominal surgery, the incidence of infection was significantly higher in the group receiving 80% oxygen than in the group receiving 35% oxygen (25% vs. 11.3%, respectively; P=0.02).

In contrast, a meta-analysis (Al-Niaimi A et al, 2009) of randomized, controlled trials evaluating the efficacy of supplemental perioperative oxygenation vs. standard care for prevention of SSI in patients undergoing colorectal surgery found a reduced incidence of SSI (R 0.70 [95% CI 0.52-0.94]; P=0.01). The authors stated that their analysis demonstrated that supplemental perioperative oxygenation is beneficial in preventing SSI in patients undergoing colorectal surgery and recommended further study of results from other types of surgery. Although supplemental oxygen appears to offer benefits, it is not a standard recommendation.

What is the effect of incision care on surgical site infections?

Patients tend to prefer wound closures that will minimize scarring, but not all surgical wounds should be closed. A prospective study revealed higher wound infection rates when contaminated abdominal incisions were closed after surgery compared to packing for 3 days and evaluating for signs of infection prior to closure (Cohn SM et al, 2001). With respect to drains, the data are unclear as to their effectiveness in preventing SSI. Some studies showed that drains in clean or clean-contaminated wounds do no affect on the development of SSI, while others show an increase in infection.

Which initiatives have been promoted as a means of reducing surgical site infections?

Initiatives to reduce SSI focus on aspects of risk ranging from improving control of the physical care of the patient to information-gathering efforts such as broader reporting of infection rates. Major initiatives are described in this section.

Guideline for Prevention of Surgical Site Infection, 1999: The Centers for Disease Control and Prevention (CDC) published one of the most comprehensive and widely-used SSI guidelines in the United States. The CDC guidelines provide specific details about risk and prevention of SSI. Information includes patient characteristics that contribute to increased SSI risk, such as diabetes, smoking, or prolonged hospital stay. Evidence-based information is provided about preoperative, operative, and postoperative procedures that have been clinically demonstrated to reduce infection risk. Surveillance methods with appropriate feedback to surgeons and infection control professionals are described to assist institutions in monitoring the incidence of SSI. Each recommendation in the CDC guideline is ranked by the level of scientific information available to support it. An updated guideline is currently being formulated by the CDC.

National Healthcare Safety Network (NHSN): The National Healthcare Safety Network (NHSN) is a voluntary, Internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at the CDC. Data are collected from participating healthcare facilities to estimate adherence to practices known to be associated with prevention of healthcare-associated infections (HAIs). The NHSN conducts research with member facilities to gather data about the epidemiology of emerging HAIs and pathogens, assess risk factors, determine mechanisms of resistance, and evaluate prevention strategies.

Guidance on Public Reporting of Healthcare-Associated Infections: The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) has established a guidance document for reporting healthcare-associated infections. This document is designed to assist policymakers who create mandatory public reporting systems to track health-associated infections. The HICPAC recommendations suggest using outcome measures including surgical antimicrobial prophylaxis and SSIs following selected procedures.

AORN Perioperative Standards and Recommended Practices:The Association of Operating Room Nurses (AORN) publishes annual guidelines that include recommended skin preparation procedures designed to reduce damage to skin tissue and decrease the risk of infection. Specific guidelines include:

  • Assessing and documenting the condition of the surgical site before skin preparation

  • Leaving hair intact at the surgical site whenever possible to avoid skin damage during removal

  • Thoroughly cleaning the surgical site

  • Applying an antiseptic agent to the surgical site and surrounding areas

  • Preparing the skin in a manner that preserves skin integrity and prevents injury

Institute for Healthcare Improvement 5 Million Lives Campaign: The Institute for Healthcare Improvement (IHI) launched the 5 Million Lives Campaign to improve the quality of American healthcare by protecting patients from 5 million incidents of medical harm between December 2006 and December 2008. As part of the ongoing campaign, the IHI developed a guideline publication designed to share best practice knowledge for the prevention of SSI. These practices include 4 components of care:

1. Appropriate use of prophylactic antibiotics

2. Appropriate hair removal

3. Controlled 6 a.m. postoperative serum glucose in cardiac surgery patients

4. Immediate postoperative normothermia for colorectal surgery patients

Surgical Care Improvement Project (SCIP):SCIP is a national quality partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications. The goal of the partnership is to save lives by reducing the incidence of surgical complications by 25% by the year 2010. Infection prevention processes and outcome measures include:

  • Prophylactic antibiotic received within 1 hour prior to surgical incision

  • Prophylactic antibiotic selection for surgical patients

  • Prophylactic antibiotics discontinued within 24 hours after surgery end

  • Cardiac surgery patients with controlled 6 a.m. postoperative blood glucose

  • Surgery patients with appropriate hair removal

  • Colorectal surgery patients with immediate postoperative normothermia

  • Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period

What is the interplay between surgical site infections and transplantation?

Healthcare-associated infections associated with solid organ transplantation (SOT) are problematic due to the invasiveness of the surgical procedures used, underlying disease, and immunosuppressive treatments. In one retrospective cohort study that assessed infection rates in 81 patients undergoing SOT over 14 months, the overall healthcare-associated infection rate was 42%, with 15% attributed to SSI. This study found that the length of surgery also contributed to high SSI rates. The authors concluded that stricter controls in controllable factors in this patient population, such as length of surgery, are necessary to reduce the substantially higher SSI rate associated with SOT.

What is the impact of xenotransplantation on surgical site infections?

Xenotransplantation is the transfer of viable cells, tissues, or organs from nonhuman animal species for therapeutic use in humans. Xenotransplantation is thought to be a potential solution to the shortage of human organs and other tissues for transplantation, but the introduction of non-human living cells into a human immunological system poses risks for development of xenogeneic infections. Specifically, human recipients of xenografts may be exposed to endogenous retroviruses present in the genomes of other species.

While infections are always a risk in transplant (allograft) patients, xenograft recipients may be at increased risk due to the greater levels of immunosuppression needed and the novel mechanisms of pathogens found in non-human living tissue. For example, potential pathogens from swine range from organisms likely to cause disease in immunocompromised transplant recipients to pathogens known to infect pigs. In addition to concerns about transplant patients themselves, public health concerns center on the possibility that infections could by transmitted by xenograft recipients to the general population. Unfortunately, there are not enough data to adequately quantify these risks.

What are the key principles for preventing surgical site infections?

Preoperative:

  • Tobacco cessation at least 30 days prior to elective surgery

  • Antimicrobial prophylaxis

    Use the correct agent for the type of operation

    Administer 30 to 60 minutes prior to incision

    Readminister if surgery is delayed beyond 1 hour after the first dose

    Maintain at therapeutic levels throughout surgery

    Discontinue no later than 24 hours after the end of surgery

  • Preoperative showering with chlorhexidine gluconate 4% solution the night before surgery

  • No hair removal or, if hair removal is necessary, clipping immediately prior to surgery

  • Preoperative skin antisepsis with an effective, broad-spectrum, fast-acting antimicrobial with persistent effects, such as 2% chlorhexidine gluconate with 70% isopropyl alcohol

  • Preoperative scrubbing of arms and hands for at least 5 minutes prior to surgery and between 2 and 5 minutes for each subsequent procedure

Perioperative:

  • Prevent intraoperative hypothermia

  • Monitor and control glucose levels at HbA1c <7%

  • Consider supplemental oxygen to prevent perioperative hyperoxia

  • Pack contaminated abdominal wounds and evaluate for signs of infection before closing

What are the consequences of not working to prevent surgical site infections?

  • Patients with SSI are twice as likely to die, 60% more likely to be admitted to the intensive care unit, and more than five times more likely to be readmitted to the hospital after discharge

  • Onset of an SSI is estimated to increase a hospital stay by 7 to 10 days and add over $3,000 in costs of care

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