Elsevier

Surgery (Oxford)

Volume 27, Issue 10, October 2009, Pages 426-430
Surgery (Oxford)

Infection
Surgical-site infection

https://doi.org/10.1016/j.mpsur.2009.08.007Get rights and content

Abstract

Surgical-site infection (SSI) is the most common healthcare-associated infection (HCAI). Between 5 and 10% of patients undergoing surgery are estimated to develop an SSI with an associated increased length of stay and increase in morbidity and mortality. SSIs place a financial burden of 1 billion pounds per annum on National Health Service resources. The majority of SSIs are preventable. Measures can be taken at the pre-operative, intra-operative and post-operative stage to reduce the risk of developing an SSI.

Section snippets

Definition

Surgical-site infection (SSI) is defined by the Centres for Disease Control and Prevention (CDC) as a proliferation of pathogenic micro-organisms which develops in an incision site either within the skin and subcutaneous fat (superficial), musculo-fascial layers (deep), or in an organ or cavity, if opened during surgery (Table 1 and Figure 1).

Since the skin is normally colonized by bacterial flora, an SSI cannot be diagnosed by the microbiological evidence alone but in conjunction with clinical

Epidemiology

Surgical-site infections are the commonest form of hospital acquired infection.1, 2 In 2002, the Nosocomial Infection National Surveillance Service (NINSS) reported an incidence of hospital acquired infection (HAI) relating to surgical wounds as high as 10% based on a five-year survey of hospitals in the United Kingdom.2 A prevalence survey undertaken in 2006 suggested that approximately 5% of patients who had undergone a surgical procedure were found to have developed an SSI.3 These studies

Pathology of surgical-site infection

All surgical wounds are contaminated with microbes, but the main do not lead to SSIs due to the efficient defences of the patient's immune system. The risk of developing an SSI is dependent on three main determinants: the type of pathogenic organisms, patient factors and procedure-related factors.

In the majority, SSIs are derived from bacteria which are part of the normal flora of the skin. However, if a body cavity is entered, such as the large bowel, then a variety of anaerobic and aerobic

Causative organisms

The most common group of microorganisms to cause an SSI is the Gram-positive cocci, mainly Staphylococcus aureus. However, Gram-negative aerobic bacteria can cause SSIs after intestinal surgery and can act in synergy with anaerobes. Other causative organisms are rare and can include transients and opportunistic bacteria, particularly in immunocompromized patients.

The emergence of methicillin-resistant strains of S. aureus (MRSA) have increased the morbidity and mortality from wound infections.

Adopt all preventive measures

Surgical care should start with meticulous adherence to strategies proven to reduce the risk of SSIs. Preoperatively, attention should be paid to factors like optimisation of patient status by addressing modifiable factors such as ensuring optimum glycaemic control in diabetics, stopping smoking, improving nutritional state and correcting anaemia.

Proper asepsis and surgical site preparation are imperative. Antibiotics should be administered on induction of anaesthesia if prophylaxis is

Obtain specimens for culture

For patients with clinical evidence of SSI, samples of purulent fluid or infected tissue should be sent for microscopy, culture and antibiotic sensitivity analysis. Blood cultures should be taken if the patient develops clinical features of systemic infection, such as fever or rigors. Microbial specimens should ideally be taken prior to starting any antibiotics.

Initiate empirical antimicrobial therapy

Empirical antibiotic treatment should be initiated based on local antimicrobial guidelines.

Target antimicrobial therapy

Antibiotic therapy should be changed

Avenues for future research

The NICE research group also identified three areas for future research into the prevention of SSIs.

Surveillance

In the current era of regional and nationwide monitoring of surgical morbidity and mortality, improvements to service can be made only if results are shared. The Surgical Site Infection Surveillance Service has been collecting data from hospitals using a standard format since 1997. Specific surgical procedures identified which carried a high rate of SSI were limb amputation (14.9-fold increase), complex hepatopancreaticobiliary surgery (11.3-fold increase), small bowel surgery (10.1-fold

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