Preventing Surgical Site Infections

Ilker Uçkay; Stephan Harbarth; Robin Peter; Daniel Lew; Pierre Hoffmeyer; Didier Pittet

Expert Rev Anti Infect Ther. 2010;8(6):657-670.

Abstract and Introduction

Abstract

The risk of surgical site infection (SSI) is approximately 1–3% for elective clean surgery. Apart from patient endogenous factors, the role of external risk factors in the pathogenesis of SSI is well recognized. However, among the many measures to prevent SSI, only some are based on strong evidence, for example, adequate perioperative administration of prophylactic antibiotics, and there is insufficient evidence to show whether one method is superior to any other. This highlights the need for a multimodal approach involving active post-discharge surveillance, as well as measures at every step of the care process, ranging from the operating theater to postoperative care. Multicenter or supranational intervention programs based on evidence-based guidelines, 'bundles' or safety checklists are likely to be beneficial on a global scale. Although theoretically reducible to zero, the maximal realistic extent by which SSI can be decreased remains unknown.

Introduction

Healthcare-associated infections (HAIs) are frequent on surgical wards^[1,2] and represent a high burden on patients and hospitals^[1,3] in terms of morbidity, mortality, prolonged length of hospital stay and additional costs.^[4] Surgical site infections (SSIs) are an important source^[1] and may even be the most frequent HAI after excluding asymptomatic bacteriuria.^[5] Apart from endogenous risk factors, such as immune suppression,^[6–8] obesity^[9] or advanced age,^[10] the role of external risk factors in SSI pathogenesis is now clearly established.^[1,3] Multimodal,^[11] multicenter or supranational preventive intervention programs based on guidelines,^[1,12] 'bundles'^[13,14] or safety checklists^[15] are gaining momentum on a global scale.^[16,17] In parallel, randomized studies provide insight into poorly explored risk factors and practical intervention measures. The National Institute for Health and Clinical Excellence (NICE) in England, Wales and Northern Ireland issued guidance for the prevention and treatment of SSI^[201] in October 2008, and the 1999 SSI guidelines of the CDC are currently under revision.

We summarize the state-of-the-art regarding SSI prevention among adult inpatients, highlight important epidemiological features and discuss pitfalls of surveillance and the possible role of benchmarking SSI rates. The practical questions regarding the most effective measures to reduce SSI and the SSI rates achievable today are also addressed, as well as the theoretical possibility of achieving a zero SSI policy on a surgical ward, at least for clean orthopedic surgery.^[3]

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Table 1. Surgical site infection rates: current benchmarks (selected papers).
Type of surgery	Group of surgery	Incidence (no. of operations)	Ref.
Surgery in industrialized countries	Gynecologic surgery	3.4% (1366) 3.7% (162) 2.4% (29,415)	^[10] ^[167] ^[35]
	General surgery	5.2% (4665) 4.7% (9195) 4.5% (4147) 3.1% (10,253) 2.4% (4472)	^[167] ^[6] ^[139] ^[34] ^[82]
	Cardiac surgery	3.6% (240)	^[7]
	Vascular surgery	2.5% (6281)	^[35]
Surgery in resource-poor settings		13% in Vietnam (582) 22% in Tanzania (527) 23% in Belgrade, Serbia (277)	^[36] ^[37] ^[38]
Clean elective surgery	Orthopedic surgery	1.1% (26,904)	^[10]
	Breast reconstruction	3.6% (136) 2.0–2.5% (review of >10,000 operations)	^[168] ^[169]
Dirty contaminated surgery	Colorectal surgery	23% (81) 26% (176) 20% (298) 18.9% (338)	^[152] ^[170] ^[171] ^[167]

Table 2. Surgical site infection in elective orthopedic surgery (selected series).
Type of orthopedic surgery	Risk of surgical site infection	Ref.
Primary hip and knee arthroplasties	0.8% Norwegian Arthroplasty Register (73,000 arthroplasties)	^[43]
	0.5% deep arthroplasty infections, Norway (22,170 procedures)	^[44]
	0.9% Finnish National Register (4628 arthroplasties)	^[45]
	0.9% Geneva Arthroplasty Register (6101 arthroplasties)	^[28]
	0.9% USA inpatient sample (496,018 arthroplasties)	^[46]
Elbow arthroplasties	3.6% (2458 arthroplasties)	^[172]
Femoral osteosynthesis	3.9% (541 operations) 3.5% (2505 operations)	^[173] ^[35]
Pin track care	11% (285 operations)	^[174]
Foot and ankle surgery	1.6% (555 operations)	^[175]
Hallux valgus (Lapidus procedure)	1.3% (61 operations)	^[176]
Hallux valgus (Chevron procedure)	5.4% (56 operations)	^[177]
Arthroscopies	0.1–0.4% (552,258 procedures)	^[40]
	0% (437 procedures)	^[41]

Table 3. Independent risk factors for surgical site infection (selected studies with odds ratios and 95% confidence intervals).
Endogenous risk factors	OR (95% CI)^†	Exogenous risk factors	OR (95% CI)
Dirty contaminated surgery^[34,36]	8.7 (4.6–16.4)	Suboptimal prophylaxis dosing^[6]	3.4 (1.5–7.9)
Diabetes mellitus^[7,11]	4.5 (2.4–9.3) 4.8 (2.3–10.4)	Omitting prophylaxis redosing if surgery >4 h^[82]	3.1 (0.8–12.9)
BMI >30 kg/m² ^[2,9]	4.1 (11.1–19)	Change of surgeon during operation^[54]	2.9 (2.0–4.0)
Inpatient versus outpatient surgery^[178]	2.9 (2.6–3.2)	Transplant surgery^[8]	2.9 (3.4–12.7)
History of prior surgery^[34]	2.4 (1.6–3.7)	Hair removal (razor) the day before^[38]	2.8 (1.2–6.3)
Age >68 years^[7]	2.4 (1.3–4.6)	Wound class^[10]	2.6 (2.2–3.0)
Hyperglycemia >200 mg/dl^[8]	2.3 (1.3–4.0)	Suction drainage for >3 days^[167]	2.2 (1.4–3.4)
ASA Score >2 points^[10,38]	1.9 (1.6–2.2)	Hectic movement in operating theater^[54]	1.8 (1.1–3.0)
Radiotherapy^[178]	1.9 (1.6–2.6)	Duration surgery >75th percentile^[34,167]	1.8 (1.2–2.4)
Postoperative pain^[178]	1.6 (1.4–1.8)	Presence of visitors during surgery^[54]	1.8 (1.3–2.5)
Low serum albumin^[34]	1.8 (1.1–2.8)	Emergency surgery^[34,36]	1.7 (1.2–2.4) 2.1 (1.2–3.9)
Chronic obstructive pulmonary disease as a comorbidity^[178]	1.7 (1.0–2.8) 1.2 (1.1–1.3)	Preoperative hospital stay >1 day^[179]	1.5 (1.1–2.0)
Vascular disease as a comorbidity^[178]	1.4 (1.3–1.6)	Smoking^[178]	1.3 (1.2–1.3)
High platelet count >400,000/µl^[178]	1.3 (1.2–1.4)	Perioperative transfusions^[178]	1.3 (1.1–1.7)
Cholestasis^[178]	1.2 (1.1–1.2)	Steroid use^[178]	1.3 (1.2–1.5)
Bleeding disorder^[178]	1.1 (1.1–1.2)	1.3 (1.2–1.5)

^†OR with 95% CI in decreasing order (selected studies).
ASA: American Society for Anesthesiology Score; OR: Odds ratio.

Table 4. Main measures to prevent surgical site infection.
Measure	SSI reduction (%) and/or OR (95% CI)
*High impact*
Active post-discharge surveillance	57%, The Netherlands^[96] 33%, France^[10] 38%, Northern France^[22] Reduction in Germany, OR: 0.8 (0.7–0.9)^[35]
Multimodal intervention	27%, USA^[13,201] 57%, AZ, USA, OR: 0.2 (0.1–0.5)^[11] 51%, Germany, OR: 0.3 (0.13–0.70)^[7]
Correct antibiotic prophylaxis	18%, Tanzania^[37] 73%, among orthopedic patients in the USA^[51]
Promising impact, needs further studies
Nasal mupirocin, Staphylococcus aureus decolonization	54%, Dutch meta-analysis, risk ratio: 0.60 (0.4–0.7)^[106]
Supplemental oxygen	23% in a meta-analysis, OR: 0.74 (0.6–0.9)^[125]
Hair clipping before surgery	OR: 0.50 (0.3–0.9)^[179]

OR: Odds ratio; SSI: Surgical site infection.

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