The United States Centers for Disease Control and Prevention (CDC) has
developed criteria that define SSI as infection related to an operative
procedure that occurs at or near the surgical incision within 30 days
of the procedure or within 90 days if prosthetic material is implanted
at surgery. SSIs are often localized to the incision site but can also
extend into deeper adjacent structures.
Clinical criteria for defining SSI include one or more of the following
●A purulent exudate draining from a surgical site
●A positive fluid culture obtained from a surgical site that was closed
primarily
●A surgical site that is reopened in the setting of at least one clinical sign
of infection (pain, swelling, erythema, warmth) and is culture positive or
not cultured
●The surgeon's diagnosis of infection
Among surgical patients, SSIs are the most common nosocomial infection.
RISK FACTORS FOR SSI
SURGICAL PLANNING
Timing of surgery: including emergency surgery, cancer therapy, remote
infection, and malnutrition.
Emergency surgery — Patients undergoing emergent or urgent surgical
procedures have higher risk of adverse outcomes, including SSI.
Cancer therapy — Chemotherapy and radiation therapy increase the risk
of subsequent SSI.
Remote infection — prior to elective surgery, patients with evidence of
active infection at a remote site should complete treatment for the
infection prior to surgery, particularly in circumstances when placement
of prosthetic material is anticipated.
Malnutrition — Hypoalbuminemia increases the risk of SSI sixfold
compared with normal albumin
Medication management — Immunosuppressive therapies impair wound
healing.
Minimally invasive versus open approach — minimally invasive and
laparoscopic-assisted procedures are generally associated with lower
rates of SSI than open procedures.
PATIENT PREPARATION
Smoking cessation — Smoking cessation four to six weeks is
recommended prior to elective surgery to reduce the risk of pulmonary
complications; smoking cessation also reduces wound complications
including SSI.
Bowel preparation — Bowel preparation prior to colon surgery reduces
SSI rates.
INFECTION CONTROL — the most important factors in the prevention
of SSI are timely administration of effective preoperative antibiotics
and careful attention to operative technique.
A number of other infection control interventions have been used to
reduce the risk of SSIs, including hand hygiene, skin antisepsis, use of
gloves and other barrier devices by operating room personnel, and patient
decolonization.
Antimicrobial prophylaxis — Antimicrobial prophylaxis is an important
intervention for prevention of SSI; it is discussed in detail separately.
Hand hygiene The recommended duration of scrubbing with alcohol-based
hand rubs is shorter than with antimicrobial soap (varies by product), and
scrub brushes are not required for preoperative hand cleaning by surgical
staff
Removal of nail polish, false nails, and finger rings prior to surgical
scrubbing is a common-sense practice, although data evaluating the
effect of these interventions on preventing SSI are limited
Surgical attire and barrier devices
We agree with the following guidelines issued by the American College of
Surgeons (ACS) regarding surgical attire:
●Scrubs should not be worn during patient encounters outside the
operating room.
●Operating room scrubs should not be worn outside the hospital
perimeter. Scrubs worn within the hospital perimeter should be
covered by a clean lab coat or other appropriate cover-up.
●Scrubs and hats worn during contaminated or dirty cases should be
changed before subsequent cases, even if not visibly soiled.
●Visibly soiled scrubs should be changed as soon as is feasible.
●The mouth, nose, and hair should be covered during all invasive
procedures. Jewelry worn on the head and neck should be removed or
covered.
Gloves protect surgical
S. aureus decolonization — Routine preoperative Staphylococcus
aureus screening and decolonization of the patient has not been
definitively proven to be beneficial or cost-effective for patients
undergoing surgery .The optimal approach to S. aureus screening and
decolonization remains uncertain and should be tailored to individual
clinical circumstances.
S. aureus decolonization may be reasonable for surgical patients known to
be nasal carriers of S. aureus who have a high risk of deleterious
outcomes should S. aureus infection develop at the surgical site (such as
patients undergoing cardiothoracic surgery, patients undergoing
orthopedic procedures with hardware implantation, or patients who are
immunocompromised
Skin antisepsis — Routine application of antiseptics to the skin should be
performed prior to surgery to reduce the burden of skin flora.
Hair removal — Shaving hair with razors at the planned operative site
should be avoided; if hair removal is absolutely necessary, it may be
performed with clippers or depilatory agents.
Preoperative hair removal has been associated with an increased risk for
SSI .One meta-analysis including 19 trials concluded no hair removal was
associated with a significantly lower risk of SSI compared with hair
removal via shaving (relative risk [RR] 0.56, 95% CI 0.34 to 0.96) [91]. Of
hair removal methods, shaving was associated with the highest risk of
SSI, followed by clipping and depilatory creams. In one study, rates of
SSI associated with shaving, clipping, or depilatory creams were 5.6, 1.7,
and 0.6 percent, respectively
OTHER PERIOPERATIVE MEASURES
Maintain normothermia —
Limit traffic through operating room —
Use of laminar airflow — Laminar flow is designed to move particle-free
air over the aseptic operating field at a uniform velocity (vertically or
horizontally).
Supplemental oxygen —
Minimize red cell transfusion — Red cell transfusions are associated with
increased SSI rates among hospitalized patients
Glucose control — Postoperative hyperglycemia has been associated with
an increased risk of infection.
SURGICAL TECHNIQUE — Good surgical technique reduces the risk of
surgical site infections.
Minimize tissue ischemia — Excessive use of electrosurgical devices can
increase thermal spread and tissue necrosis at and beyond the site of
application
Topical and local antibiotic delivery — Various topical and local antibiotic
delivery methods have been used in an attempt to reduce the incidence of
SSI, including antibiotic irrigation, topical antimicrobial agents,
antimicrobial dressings, and wound sealants.
Wound protectors and other devices — Wound protectors are devices
designed to protect the abdominal wound edges from contamination and
trauma
Antibiotic sutures — the use of antibiotic sutures may be associated with
a reduced risk of SSI
We suggest NOT using routine preoperative Staphylococcus
aureus screening and decolonization for patients undergoing surgery. The
optimal approach to S. aureus screening and decolonization remains
uncertain and should be tailored to individual clinical circumstances.
Preoperative S. aureus decolonization may be reasonable for surgical
patients known to be nasal carriers of S. aureus with a high risk of
deleterious outcomes should S. aureus infection develop at the surgical
site (such as patients undergoing cardiothoracic surgery, patients
undergoing orthopedic procedures with hardware implantation, or patients
who are immunocompromised).
Overview of control measures for prevention of surgical site infection
in adults
Skin antisepsis
Chlorhexidine may be superior to iodine because chlorhexidine is not
inactivated by blood or serum.
Hair removal — Shaving hair with razors at the planned operative site
should be avoided; if hair removal is absolutely necessary, it may be
performed with clippers or depilatory agents.
The timing of hair removal is also important; the lowest rates of SSI have
been observed when hair was removed just prior to the surgical incision
The predominant organisms causing surgical site infections (SSIs) after clean
procedures are skin flora, including streptococcal species, Staphylococcus aureus,
and coagulase-negative staphylococci. In clean-contaminated procedures, the
predominant organisms include gram-negative rods and enterococci in addition to
skin flora. When the surgical procedure involves a viscus, the pathogens reflect
the endogenous flora of the viscus or nearby mucosal surface; such infections are
typically polymicrobial.
Patients who receive prophylactic antibiotics within one to two hours before the
initial incision have lower rates of SSI than patients who receive antibiotics sooner
or later than this window
Cefazolin is a drug of choice for many procedures; it is the most widely studied
antimicrobial agent with proven efficacy for antimicrobial prophylaxis
Antimicrobial therapy should be initiated within the 60 minutes prior to surgical
incision to optimize adequate drug tissue levels at the time of initial incision
