Updated Recommendations for Control of Surgical Site Infections

J. Wesley Alexander, MD, ScD; Joseph S. Solomkin, MD; Michael J. Edwards, MD

Disclosures

Annals of Surgery. 2011;253(6):1082-1093. 

In This Article

Abstract and Introduction

Abstract

Objective: The objective of this study is to provide updated guidelines for the prevention of surgical wound infections based upon review and interpretation of the current and past literature.
Background: The development and treatment of surgical wound infections has always been a limiting factor to the success of surgical treatment. Although continuous improvements have been made, surgical site infections continue to occur at an unacceptable rate, annually costing billions of dollars in economic loss caused by associated morbidity and mortality.
Methods: The Centers for Disease Control (CDC) provided extensive recommendations for the control of surgical infections in 1999. Review of the current literature with interpretation of the findings has been done to update the recommendations.
Results: New and sometimes conflicting studies indicate that coordination and application of techniques and procedures to decrease wound infections will be highly successful, even in patients with very high risks.
Conclusions: This review suggests that uniform adherence to the proposed guidelines for the prevention of surgical infections could reduce wound infections significantly; namely to a target of less than 0.5% in clean wounds, less than 1% in clean contaminated wounds and less than 2% in highly contaminated wounds and decrease related costs to less than one-half of the current amount.

Introduction

The incidence of surgical site infections continues to be unacceptably high and most of these can be prevented. A review of the literature has been done with updated recommendations, which if applied routinely, could improve patient outcomes and save billions of dollars.

The direct economic costs of an SSI are considerable, usually being approximately twice the amount of in-patient costs for a patient without an SSI (SDC-1, SDC references at https://links.lww.com/SLA/A120). However, there are extreme variations in costs, ranging from less than $400/case for minor superficial infections noted after discharge to $63,135 for complex infections after insertion of joint prosthesis and $299,237 for mediastinis after cardiac surgery (SDC-2–4). Home health care expenses after discharge may also be high – $6200/patient in one study for infections after colon resection (SDC-5). In the 1990s, the median direct cost for hospitalization in infected patients was $7531 compared to $3844 for noninfected patients (SDC-6). The increase in costs for SSI ranged from $2671 for colon surgery to $11,001 for spinal surgery.

The overall costs of SSI to society can be staggering. In a study of hospital-associated infections in Massachusetts, the cost of such infections in 2006 was $223,000,000 to $275,000,000.[1] A 1% incidence of SSI was projected to generate national costs of over $900,000,000 per year for in-hospital costs alone and a total of $1.6 billion in excess costs overall (SCD-7). Such figures may account for only 10% of overall costs when including indirect social costs such as time off work and loss of job. They also do not include potential costs for malpractice litigation and less tangible items such as loss of companionship. The economic cost is not the only cost. In an NNIS survey of 387,000 patients with nosocomial infections, an organ/space infection contributed to the death in 89% of the patients so afflicted (SDC-8). In another study involving 288,906 patients of which 11.9% had an SSI,[2] in hospital mortality in infected, patients was 14.5% vs. 1.8% in noninfected patients.

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