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

Glucose Control

It has been known for decades that surgical patients with diabetes have an increased incidence of major complications including poor wound healing, wound infections, cardiac compromise, and death (SDC-225-226). Infections have been particularly problematic in diabetic patients undergoing sternotomy for open heart surgery (SDC-225, SDC-227). In a report of 8910 patients, 18% of whom were diabetic, the incidence of deep sternal wound infections (DSWI) in diabetic patients was 1.7% compared to 0.4% for nondiabetics (SDC-228) and the incidence of DSWI increased with higher levels of blood glucose (SDC-Fig. 3 at https://links.lww.com/SLA/A123). Implementation of a protocol during this period of observation to decrease blood levels to less than 200 mg/dL in the immediate postoperative period resulted in a significant decrease in the incidence of DSWI from 2.4% to 1.5%. In another study involving 3065 patients, institution of a protocol to prevent hyperglycemia resulted in a reduction of DSWI from 2.6% to 1.0% (SDC-229). Protocols to keep blood glucose levels between 120 and 160 mg/dL for the first 2 to 3 days postoperatively have resulted in a reduction of DSWI to levels comparable to nondiabetic patients (SDC-229-231). Patients with hyperglycemia who did not have a prior diagnosis of diabetes have approximately the same infection rate as those with known diabetes (SDC-225, SDC-227, SDC-231).

The adverse effect of poor glucose control (> 150 mg/dL) is also evident in other types of procedures. In a retrospective study of 995 patients undergoing general and vascular operations, the incidence of postoperative infection increased by 30% for every 40% increase in blood glucose above 110 mg/dL (SDC-232). Hyperglycemia has also been associated with an increase in wound infections after colorectal surgery SDC-233) spinal surgery (SDC-234), pancreatic surgery (SDC-235), vascular surgery (SDC-236-237), and mastectomy (SDC-238).

There are numerous adverse effects of hyperglycemia on the immune system (SDC-239). These include disturbances of microvascular responses, inhibition of complement function, increases in proinflammatory cytokine levels and some chemokines, inhibition of chemotaxins, impaired phagocytosis and intracellular killing (especially by PMNs) and disturbances in reactive oxygen species. There is also a dose-dependent decrease in T and B cell responses and an increased apoptosis and oxidative stress in the lymphocytes. Catecholamines, growth hormones, and corticosteroids are all increased by hyperglycemia, all inhibiting O2 delivery to wounds.

Interpretation

Hyperglycemia is a risk factor for SSI independent from diabetes. High levels of glucose impair numerous host defense mechanisms and the risk of SSI increases with increases of blood glucose. However, with aggressive treatment with insulin, there is a risk of clinically significant hypoglycemia. Close monitoring is essential. We recommend less than 180 mg/dL for a maximal glucose target.

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