Surgical Site Infections

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Epidemiology

SSIs are a devastating and common complication of hospitalization, occurring in 2% to 5% of patients undergoing surgery in the United States.2 As many as 15 million procedures are annually performed in the United States; thus, approximately 300,000 to 500,000 SSIs occur each year.3 SSI is the second most common type of health care–associated infection (HAI).4 Staphylococcus aureus is the most common cause of SSI, occurring in 20% of SSIs among hospitals that report to the Centers for Disease

Diagnosis

Most SSIs that do not involve implants are diagnosed within 3 weeks of surgery.14 The CDC’s National Healthcare Surveillance Network (NHSN) has developed standardized criteria for defining an SSI (Box 1).15 SSIs are classified as either incisional or organ/space (Fig. 1). Incisional SSIs are further classified into superficial (involving only skin or subcutaneous tissue of the incision) or deep (involving fascia and/or muscular layers). Organ/space SSIs include infections in a tissue deep to

Pathogenesis of infection

The likelihood that an SSI will occur is a complex relationship among (1) microbial characteristics (eg, degree of contamination, virulence of pathogen), (2) patient characteristics (eg, immune status, diabetes), and (3) surgical characteristics (eg, introduction of foreign material, amount of damage to tissues). Similar to taxes and death, microbial contamination of surgical sites is universal, despite the use of cutting-edge technology and expert technique. The pathogens that lead to SSI are

Risk factors

Risk factors for SSI are typically separated into patient-related (preoperative), procedure-related (perioperative), and postoperative categories (Table 2). In general, patient-related risk factors for the development of SSI can be categorized as either unmodifiable or modifiable. The most prominent unmodifiable risk factor is age. In a cohort study of more than 144,000 patients, increasing age independently predicted an increased risk of SSI until age 65 years, but at ages 65 years or more,

Prevention

Methods to prevent SSI were recently summarized in the Society for Healthcare Epidemiology of America/Infectious Disease Society of America Compendium of Strategies to Prevent HAI in Acute Care Hospitals.78 In particular, emphasis was placed on the importance of perioperative antimicrobial prophylaxis, avoiding shaving, glucose control for cardiac surgery, and measurement and feedback of rates of SSI to surgeons. If feasible, modifiable risk factors for SSI should be addressed. Table 2

Treatment

Surgical opening of the incision with removal of necrotic tissue is the primary and most important aspect of therapy for many SSIs.127 Antimicrobial therapy is an important adjunct to surgical debridement. The type of debridement and duration of the postoperative antimicrobial therapy depend on the anatomic site of infection and invasiveness of the SSI, although deep incisional and organ/space infections almost universally require operative drainage of accumulated pus. A key consideration for

Summary

SSIs lead to an excess of health care resource expenditure, patient suffering, and death. Improved adherence to evidence-based preventative measures, particularly those related to appropriate antimicrobial prophylaxis, can decrease the rate of SSI. Diagnosis is difficult, particularly in the setting of a procedure that involved prosthetic material. In general, aggressive surgical debridement in combination with effective antimicrobial therapy are needed to optimize the treatment of SSIs.

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