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C. Karam et al.
Reducing Surgical Site Infections
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KamalM.F.Itani andGentianKristo
Introduction
Surgical site infections (SSIs) occur at or near the incision site and/or deeper underlying tissue spaces and organs within 30days of a surgical procedure (or up to 90days
when a prosthetic implant is used). They are the most common healthcare- associated
infections among surgical patients [1] and are associated with substantial morbidity.
SSIs are associated with approximately 8205 deaths each year in the United States
and account for an estimated 11% of all deaths in intensive care units [2]. They increase
the hospital stay by 11days per patient [3] and are the most frequent cause (20%) of
unplanned readmissions after surgery [4]. The nancial burden of SSIs is signicant,
with overall US cost estimates of $3.5 to $10 billion annually, approximately $12,000 to
$35,000 per patient [5]. Given that about 60% of SSIs are considered preventable [6],
SSI has become an important quality improvement and pay-for-performance metric.
In order to standardize SSI data collection, the Centers for Disease Control and
Prevention (CDC) has dened SSI based on depth and tissue space involved [7]. In
the criteria put forth by the CDC, SSIs are classied as either incisional or organ/
space, with incisional SSIs being further subclassied as supercial (involving only
skin and subcutaneous tissue) versus deep (involving underlying fascia and muscle).
Table 6.1 describes the criteria used by the CDC to classify SSI into its various
categories [8]. These criteria are used for surveillance purposes and allow for
6
K. M. F. Itani (*)
Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, MA, USA
Department of Surgery, Boston University, Boston, USA
Harvard Medical School, Boston, MA, USA
e-mail: Kamal.Itani@va.gov
G. Kristo
Department of Surgery, Veterans Affairs Boston Healthcare System, West Roxbury, MA, USA
Harvard Medical School, Boston, MA, USA
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_6
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Table 6.1 CDC surgical site infection (SSI) classication (adapted from Mangram etal. [8])
Supercial Incisional SSI
Infection occurs within 30days after the operation and infection involves only skin or
subcutaneous tissue of the incision and at least one of the following:
1. Purulent drainage, with or without laboratory conrmation, from the supercial incision
2. Organisms isolated from an aseptically obtained culture of uid or tissue from the
supercial incision
3. At least one of the following indicators of infection: pain or tenderness, localized
swelling, redness, or heat and supercial incision is deliberately opened by surgeon,
unless incision is culture-negative
4. Diagnosis of supercial incisional SSI by the surgeon or attending physician
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inammation and discharge conned to the points of suture
penetration)
2. Infection of an episiotomy or newborn circumcision site
3. Infected burn wound
4. Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI)
Note: Specic criteria are used for identifying infected episiotomy and circumcision sites and
burn wounds
Deep Incisional SSI
Infection occurs within 30days after the operation if no prosthetic implant is left in place or
within one year if implant is in place and the infection appears to be related to the operation
and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at
least one of the following:
1. Purulent drainage from the deep incision but not from the organ/space component of
the surgical site
2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following signs or symptoms: fever (>38°C), localized
pain, or tenderness, unless site is culture-negative
3. An abscess or other evidence of infection involving the deep incision is found on direct
examination, during reoperation, or by histopathologic or radiologic examination
4. Diagnosis of a deep incisional SSI by a surgeon or attending physician
Notes:
1. Report infection that involves both supercial and deep incision sites as deep incisional
SSI
2. Report an organ/space SSI that drains through the incision as a deep incisional SSI
Organ/Space SSI
Infection occurs within 30days after the operation if no prosthetic implant is left in place or
within one year if implant is in place and the infection appears to be related to the operation
and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision,
which was opened or manipulated during an operation and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab wounda into the organ/space
2. Organisms isolated from an aseptically obtained culture of uid or tissue in the organ/
space
3. An abscess or other evidence of infection involving the organ/space that is found on
direct examination, during reoperation, or by histopathologic or radiologic examination
4. Diagnosis of an organ/space SSI by a surgeon or attending physician
a
If the area around a stab wound becomes infected, it is not an SSI.It is considered a skin or soft
tissue infection, depending on its depth
K. M. F. Itani and G. Kristo
6 Reducing Surgical Site Infections
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objective denitions in quality improvement, public reporting, pay-for-performance
and research.
89
Microbiology ofSSIs
In most SSIs, the responsible pathogens originate from the patient’s endogenous
ora. Overall, the most commonly involved organisms are Staphylococcus
aureus, coagulase-negative staphylococci, Enterococcus spp., and Escherichia
coli [8]. However, the specic pathogens isolated depend primarily on the type
of surgical procedure performed. In clean surgical procedures, in which the gastrointestinal, genito-urinary, and respiratory tracts have not been entered, endogenous Staphylococcus aureus from the patient’s skin ora is the usual cause of
infection. Entry into hollow viscera exposes surrounding tissue to Gram-negative
bacilli such as Escherichia coli, Gram-positive organisms such as Enterococcus
spp., anaerobes such as Bacillus fragilis, and, occasionally, yeast species [8].
Pathogens may also originate from preoperative infections at sites remote from
the operative site, particularly in patients undergoing insertion of prosthetic
implants.
In addition to the patient’s endogenous ora, SSI pathogens may originate from
exogenous sources such as colonized surgical team personnel, operating room environment, and instruments and materials used during the surgical procedure. Such
pathogens are predominantly aerobes, particularly Gram-positive organisms such as
staphylococci and streptococci.
The risk of SSI caused by resistant bacteria has become a major healthcare concern. In particular, there is concern about the rise in SSIs due to methicillin-resistant
S. aureus (MRSA), vancomycin-resistant Enterococci (VRE), third-generation
cephalosporin-resistant Escherichia coli, and imipenem- and quinolone-resistant
Pseudomonas aeruginosa. Antimicrobial resistance among nosocomial pathogens
often results in prolonged periods of antimicrobial therapy and increased treatment
costs, prolonged hospital stays, and higher mortality [9]. For adequate antimicrobial
stewardship, antibiotic prophylaxis for surgical interventions should consider the
expected ora, bacterial resistance patterns, drug pharmacokinetics and recommended duration not to exceed 24h.
Table 6.2 further expands upon the most likely pathogens encountered in different surgical procedures.
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Table 6.2 Pathogens commonly associated with different surgical procedures (adapted from
Mangram etal. [8])
Type of surgery Common pathogens
Placement of all grafts,
prostheses, or implants
Cardiac S. aureus; coagulase-negative staphylococci
Thoracic S. aureus; coagulase-negative staphylococci, Streptococcus
Breast S. aureus; coagulase-negative staphylococci
Ophthalmic S. aureus; coagulase-negative staphylococci; streptococci;
Orthopedic S. aureus; coagulase-negative staphylococci; streptococci;
Vascular S. aureus; coagulase-negative staphylococci
Appendectomy Gram-negative bacilli; anaerobes
Biliary tract Gram-negative bacilli; anaerobes
Colorectal Gram-negative bacilli; anaerobes
Gastroduodenal Gram-negative bacilli; streptococci; oropharyngeal
Head and neck S. aureus; streptococci; oropharyngeal anaerobes (e.g.,
Obstetric and gynecological Gram-negative bacilli; enterococci; Group B streptococci;
Urological Gram-negative bacilli
S. aureus; coagulase-negative staphylococci
pneumoniae, Gram-negative bacilli
Gram-negative bacilli
Gram-negative bacilli
anaerobes (e.g., peptostreptococci)
peptostreptococci)
anaerobes
K. M. F. Itani and G. Kristo
Risk Factors
Several modiable and non-modiable patient (intrinsic) risk factors have been
identied for the development of SSIs. Potentially modiable patient risk factors
include diabetes, obesity, dyspnea, alcoholism, smoking, preoperative albumin
<3.5 mg/dL, total bilirubin >1.0 mg/dL, and immunosuppression [10]. Nonmodiable patient factors include increasing age, recent radiotherapy, and history of
skin or soft tissue infection.
In addition to intrinsic factors, the role of extrinsic risk factors in the pathogenesis of SSI is well recognized [8]. Extrinsic risk factors include emergency
and more complex surgeries; higher wound classication; inadequate operating
room (OR) ventilation; increased OR trafc; improper sterilization of surgical
instruments; presence of a pre-existing infection; inadequate skin preparation;
hair removal; inadequate prophylactic antibiotic choice, administration, and
duration; prolonged duration of surgery; intraoperative blood transfusion;
improper surgical hand scrubbing and gloving; and intraoperative hypothermia
and poor glycemic control [10]. Table6.3 further expands upon the risk factors
for developing SSI.
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91
Table 6.3 Risk factors for surgical site infections (adapted from Ban etal. [10])
Intrinsic (Patient) risk factors Extrinsic (Procedural) risk factors
Modiable Non- modiable Procedure Facility Pre-operative Intra- operative
Diabetes
Obesity
Alcoholism
Current smoker
Preoperative albumin
<3.5mg/dL
Total bilirubin
>1.0mg/dL
Immunosuppression
Increased age
Recent
radiotherapy
History of
skin or soft
tissue
infection
Emergency
Increasing
complexity
Higher
wound
classication
Inadequate
ventilation
Increased
operating room
trafc
Contaminated
environmental
surfaces
Non-sterile
equipment
Pre-existing
infection
Inadequate skin
preparation
Inappropriate
antibiotic
choice, timing,
and
weight-based
Dosing
Hair removal
method
Poor glycemic
control
Longer procedure
duration
Blood transfusion
Breach in asepsis
Inappropriate
antibiotic
re-dosing
Inadequate
gloving
Inappropriate
surgical scrub
Poor glycemic
control
Guidelines forPrevention
Various national and international organizations have developed guidelines for the
prevention of SSI.In 1999, the CDC released expert-opinion based guidelines for
preventing SSIs [8]. The World Health Organization (WHO) published their SSI
prevention guidelines in 2016 [11] and the American College of Surgeons and the
Surgical Infection Society (ACS/SIS) published theirs in 2017 [10]. The CDC
updated its SSI prevention guidelines in 2017, based on a systematic review and
grading of the medical literature [12].
These guidelines agree on most preventative measures. Each guideline also
addresses additional measures based on the level and quality of evidence
established for the guideline as well as the target audiences and priorities for
each organization. Their summarized recommendations are discussed in
detail below.
Prehospital Interventions
Prehospital interventions for reducing SSI include preoperative bathing, smoking cessation, glucose control, MRSA screening, and bowel preparation
(Table6.4).
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Table 6.4 Guidelines for prehospital interventions as endorsed by specic guidelines (adapted
from Ban [10], Allegranzi [11], and Berrios-Torres [12])
Guideline (Organization) Recommendation
Preoperative bathing (CDC;
ACS/SIS; WHO)
Smoking cessation (CDC; ACS/
SIS)
Glucose control (CDC; ACS/
SIS; WHO)
MRSA screening (ACS/SIS;
WHO)
Bowel preparation (ACS/SIS;
WHO)
CDC Centers for Disease Control and Prevention, ACS/SIS American College of Surgeons and the
Surgical Infection Society, WHO World Health Organization
Routine preoperative bathing with chlorhexidine reduces
the bacterial colonization of the skin but has not been
shown to reduce SSI
Smoking cessation 4–6weeks before surgery reduces SSI
and is recommended for all current smokers, especially
those undergoing procedures with implanted materials.
There is no literature to support cessation of marijuana and
electronic cigarette use to prevent SSI
Optimal blood glucose control should be encouraged for all
diabetic patients; however, there is no evidence that
improved Hgb A1C decreases SSI risk
MRSA bundles (screening, decolonization, contact
precautions, hand hygiene) are highly effective if adhered
to, otherwise there is no benet
No standard decolonization protocol supported by
literature; consider nasal mupirocin alone vs nasal
mupirocin plus chlorhexidine gluconate bathing
Decolonization protocols should be completed close to date
of surgery to be effective
Vancomycin should not be administered as prophylaxis to
MRSA- negative patients
Combination mechanical and antibiotic oral preparation is
recommended for all elective colectomies
K. M. F. Itani and G. Kristo
Preoperative Bathing
Routine preoperative bathing with chlorhexidine decreases skin surface pathogen
concentrations but has not been shown to reduce SSI [10].
Smoking Cessation
Smoking cessation 4–6weeks before surgery reduces SSI [10, 12] and is recommended for all current smokers, especially those undergoing procedures with
implanted materials. There is no literature to support cessation of marijuana and
electronic cigarette use to prevent SSI. There is no evidence suggesting that
alternative nicotine-containing substances (e.g., gum, patch, and lozenges) are
linked to SSI [10]. As such, their use is supported as smoking-cessation aids
before surgery.
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93
Glucose Control
Optimal blood glucose control should be encouraged for all diabetic patients; however, there is no denitive evidence that improved Hgb A1C decreases SSI risk [10].
MRSA Screening
MRSA colonization is associated with worse outcomes and a higher risk for both
MRSA SSI and SSI overall [13–15]. MRSA bundles include screening, decolonization, contact precautions, hand hygiene, and vancomycin-containing antibiotic prophylaxis. They are highly effective in reducing rates of SSI if adhered to; otherwise,
there is no benet [10]. Decolonization protocols should be completed close to the
date of surgery to be effective.
Typical preoperative decolonization protocols include the use of nasal mupirocin
alone vs. nasal mupirocin plus chlorhexidine gluconate bathing, although no standard decolonization protocol is supported by literature [10].
For antibiotic prophylaxis, use of vancomycin alone in MRSA-negative patients
is associated with a higher risk of methicillin-sensitive S. aureus SSI [16] and an
increased risk of conversion to MRSA-positive status and development of SSI [17].
As such, routine administration of vancomycin antibiotic prophylaxis in MRSAnegative patients is not recommended [10].
Bowel Preparation
Mechanical bowel preparation alone or oral antibiotics alone do not decrease SSIs
[18–20]. The combination of mechanical and oral antibiotic bowel preparations is
associated with lower rates of SSI, anastomotic leak, Clostridium difcile infection,
postoperative ileus, reduced length of stay, and lower readmission rates [18–23].
For these reasons, combination mechanical and antibiotic oral preparation is
increasingly recommended for all elective colorectal surgeries [10, 18, 19]. Routine
intravenous prophylactic antibiotics in the immediate preoperative period should
also be given.
Hospital Interventions
Hospital interventions for reducing SSI include perioperative glucose control, hair
removal, preoperative skin preparation, surgical hand scrub, surgical attire, prophylactic antibiotics, maintaining normothermia, maintaining euvolemia, wound protectors, antibiotic sutures, gloves/instruments, adhesive incise drapes, incisional
wound irrigation, operating room ventilation, and wound care (Table6.5).
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