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Updates in Surgery
StefanoBartoli
FrancescoCortese
MassimoSartelli
GabrieleSgangaEditors
Infections
in Surgery
Prevention and Management
Updates in Surgery
The aim of this series is to provide informative updates on hot topics in the areas of
breast, endocrine, and abdominal surgery, surgical oncology, and coloproctology,
and on new surgical techniques such as robotic surgery, laparoscopy, and minimally
invasive surgery. Readers will nd detailed guidance on patient selection,
performance of surgical procedures, and avoidance of complications. In addition, a
range of other important aspects are covered, from the role of new imaging tools to
the use of combined treatments and postoperative care.
The topics addressed by volumes in the series Updates in Surgery have been selected
for their broad signicance in collaboration with the Italian Society of Surgery.
Each volume will assist surgical residents and fellows and practicing surgeons in
reaching appropriate treatment decisions and achieving optimal outcomes. The
series will also be highly relevant for surgical researchers.
Stefano Bartoli
Francesco Cortese
Massimo Sartelli
Gabriele Sganga
Editors
Infections in Surgery
Prevention andManagement
Editors
https://t.me/med1917
Stefano Bartoli
Department of Vascular Surgery
Sant’Eugenio Hospital-ASL Roma 2
Rome, Italy
Francesco Cortese
Emergency Surgery Unit
San Filippo Neri Hospital
Rome, Italy
Massimo Sartelli
Department of Surgery
Macerata Hospital
Macerata, Italy
Gabriele Sganga
Emergency and Trauma Surgery Unit
Policlinico Universitario A.Gemelli IRCCS
Rome, Italy
ISSN 2280-9848 ISSN 2281-0854 (electronic)
Updates in Surgery
ISBN 978-3-031-60461-4 ISBN 978-3-031-60462-1 (eBook)
https://doi.org/10.1007/978-3-031-60462-1
The publication and the distribution of this volume have been supported by the Italian Society
of Surgery.
The Editors of the volume and the Italian Society of Surgery would like to thank Johnson &
Johnson MedTech and Becton, Dickinson Italia S.p.A. for their unconditional contribution,
which made it possible to publish this book under the Open Access model.
This book is an open access publication.
© The Editor(s) (if applicable) and The Author(s) 2025
Open Access This book is licensed under the terms of the Creative Commons AttributionNonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/by-
nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in any medium
or format, as long as you give appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license and indicate if you modied the licensed material. You do not have
permission under this license to share adapted material derived from this book or parts of it.
The images or other third party material in this book are included in the book’s Creative Commons
license, unless indicated otherwise in a credit line to the material. If material is not included in the book’s
Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder.
This work is subject to copyright. All commercial rights are reserved by the author(s), whether the whole
or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or
information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed. Regarding these commercial rights a non-exclusive
license has been granted to the publisher.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional afliations.
Revision and editing: R. M. Martorelli, Scienzaperta (Novate Milanese, Italy)
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.
Foreword
https://t.me/med1917
Asepsis, which today is a prerequisite and an integral part of any surgical procedure,
even the most trivial, is a practice that we could say has been recently acquired. It
was 1847 when Semmelweis intuited, on the basis of empirical observations, that
there was a relationship between puerperal fevers and the hygienic conditions of
women in labor, but he was isolated and ridiculed by the medical community and
died condemned to contempt in the Budapest asylum, as the beautiful biography
that Celine dedicated to him tells us. It took another 50years, and the studies of
Louis Pasteur, for the etiological relationship between microorganisms and infectious disease to be demonstrated, but since then the surgeon’s eld of action has
certainly expanded. Asepsis, along with anesthesia, revolutionized the role of surgery in medicine, allowing it to write important chapters in its history. The surgeon’s skill could nally save lives without the onset of infections threatening the
outcome of the operations.
Therefore, operating in aseptic environments, washing hands and adopting the
rules of prophylaxis derived from the maturation and application of Pasteur’s studies was to make surgery evolve quickly and achieve extraordinary results in a very
short time. This led to the birth and consolidation of the concept of safety of treatments, thanks to which surgery would be able to change the natural course of a
disease and truly help to decrease mortality from many diseases by reducing the risk
of infections.
The value of surgery today has not changed. On the contrary, it continues to
undergo small and large revolutions, and the current minimally invasive techniques
with their ability to guarantee conservative approaches constitute the clinician’s tool
of choice for the treatment of many pathological conditions.
And yet, just over a century later, surgery is still not free from the risk of infection and, due to the increase in the antibiotic resistance, healthcare-associated infections linked to surgical procedures are an incredibly topical and important issue for
the health of patients.
Surgical site infections, among the most common of the healthcare-associated
infections, are associated with many adverse outcomes causing illness, additional
surgical procedures, intensive care unit admissions, and higher mortality.
The scientic literature tells us that about 0.5–3% of patients who undergo surgery will experience an infection at or near the site of surgical incision and that
patients who undergo surgery and develop an infection related to surgical care have
v
vi
https://t.me/med1917
Foreword
an average duration of hospitalization that is about 7–11days longer than those
who do not.
This means a threat to health, the economy and, above all, to the sustainability
of care.
These gures, however, are not written in stone. Actions can be promoted to
reverse this trend and preserve the sustainability of public health protection systems. The World Health Organization states that 40–60% of these infections can be
avoided by implementing preventive measures during hospitalization, before and
after surgery. To this end, a precise pathway must be followed: the staff need to be
educated, trained, and sensitized, and actions must be put in place to improve adherence to counterstrategies against infection.
This book offers numerous knowledge tools and represents an important update
for professionals, as well as a valuable aid to promote greater awareness of this
phenomenon. In various chapters, both general and specic aspects of the problem
are addressed in a detailed and exhaustive way: epidemiology, risk factors, the
impact of these infections, as well as the role of measures such as surveillance,
antimicrobial stewardship, and Health Technology Assessment.
The contributing authors are all professionals in the eld, whose great authority
and experience have enabled them to merge clinical skills and expertise in public
health, to address the issue with a complete and exhaustive approach. The merit of
this volume, therefore, lies not only in having collected and brought up to date the
available evidence on infections related to surgical care, but also in having presented and provided, from a public health perspective, the necessary tools to reduce
the impact of this scourge that is expensive in economic terms but dramatically
more costly in terms of human lives.
September 2024
Rome, Italy
RoccoBellantone
Foreword
https://t.me/med1917
The rst Biennial Report of the Italian Society of Surgery was published in 1994,
exactly 30years ago, and in the intervening period infections in surgery have never
been addressed, perhaps because surgeons do their work predominantly in the operating room, and most of their concerns are inevitably directed at surgery.
This has led many surgeons to mistakenly consider surgical infections to be a
secondary aspect of their practice, but today the surgeon is at the forefront of infection control and management, is responsible for many of the processes that inuence infection risk and plays a key role in prophylaxis. Nevertheless, infection
prevention, control measures, and some practices, such as proper antibiotic prescription, are often inadequate.
For this reason in recent years, the leading surgical scientic societies have dedicated great attention to this topic, a sign of growing awareness of the problem.
The Italian Society of Surgery is at the front line of this challenge and that is why
the Society Governing Council and I enthusiastically welcomed Stefano Bartoli’s
proposal to publish a monograph on infections in surgery.
The involvement of Francesco Cortese, Massimo Sartelli, and Gabriele Sganga
as co-editors and co-authors, and of many experts as co-authors of the 22 chapters
forming the book, was Stefano Bartoli’s winning choice for writing a work of the
highest scientic value. To all of them go my heartfelt thanks for this excellent volume, which addresses all aspects of infections in surgery, from epidemiology to
prevention, diagnosis, and treatment, as well as economic and medico-legal
implications.
The treatise will surely be a reference for anyone, surgeons and non-surgeons
alike, and aspires to be considered a real guideline, which can also be adopted by
our Ministry of Health.
Rome, Italy
MassimoCarliniSeptember 2024
vii
Preface
https://t.me/med1917
Despite proper precautions and intraoperative measures, healthcare-associated
infections remain a major concern, increasing overall morbidity and mortality.
These infections are acquired by patients receiving medical care and represent the
most frequent adverse event affecting patient safety worldwide. The most common
healthcare-associated infections include surgical site infections, catheter-associated
urinary tract infections, central-line-associated bloodstream infections, hospitalacquired pneumonia, ventilator-associated pneumonia, and Clostridioides difcile
infection.
While signicant progress has been made in infection prevention and control,
one of the factors hindering the prevention of infections in surgery is the uneven
implementation of recommended prevention practices due to low awareness of the
problem, which is often viewed as episodic and not related to systemic factors.
Hospital-acquired infections reect an organizational deviation from best practices
that recommend adequate assessment of the patient’s characteristics and of the hospital environment.
Preventing infections in surgery requires a multidisciplinary and multiprofessional approach. Adherence to guidelines and protocols, early recognition and
proper treatment are key to signicantly reducing infection rates and improving
surgical outcomes.
Through the contribution of many experts from different disciplines, this book
aims to provide surgeons with a useful tool to further their understanding of the
various aspects of surgical infections, including prevention and control of infections
and potential sources, antimicrobial stewardship, and management of sepsis. In
each chapter, the reader will be able to nd, thanks to the authors’ experience, practical suggestions to tackle the problem of infections in surgery.
Thanks to the unconditional contribution of Johnson & Johnson MedTech and
Becton, Dickinson Italia S.p.A., the book is made available as open access so as to
reach a broad readership.
September 2024
Rome, Italy
Rome, Italy
Macerata, Italy
Rome, Italy
StefanoBartoli
FrancescoCortese
MassimoSartelli
GabrieleSganga
ix
Contents
https://t.me/med1917
1 Guidelines and Good Clinical Practice in Surgical Infection . . . . . . . . 1
Stefano Bartoli, Giulia Ianni, Gianluca Smedile,
Tommaso Castrucci, and Andrea Siani
2 Impact of Healthcare-Associated Infections in Surgery . . . . . . . . . . . . 7
Fortunato “Paolo” D’Ancona and Claudia Isonne
3 Epidemiological Framework: The Role of Surveillance . . . . . . . . . . . . 15
Enrico Ricchizzi
4 Measuring and Improving Care in Surgical Site Infections . . . . . . . . . 25
Stefano Bartoli, Giulia Ianni, Tommaso Castrucci,
Roberto Gabrielli, Andrea Siani, and Tommaso Bellandi
5 Principles of Infection Prevention and Control in Surgery . . . . . . . . . 37
Antonella Agodi
6 Multimodal Approach to Implement Infection Prevention
and Control in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Maria Luisa Moro
7 Antimicrobial Stewardship in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Nicola Petrosillo
8 Principles for Correct Surgical Antibiotic Prophylaxis
and Antibiotic Therapy
Massimo Sartelli, Guido Cesare Gesuelli, Rodolfo Scibè,
Miriam Palmieri, and Walter Siquini
9 Microbiological Diagnosis in the Era of Antimicrobial Resistance . . . 71
Gian Maria Rossolini, Alberto Antonelli, Angelo Galano,
and Tommaso Giani
10 Infection Prevention and Control in Acute Care Surgery . . . . . . . . . . . 81
Giorgia Santandrea, Carlo Vallicelli, Massimo Sartelli,
Federico Coccolini, Luca Ansaloni, Vanni Agnoletti,
and Fausto Catena
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
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