Updated Recommendations for Control of Surgical Site Infections

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


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

In This Article


It has been known for decades that cigarette smoking is associated with adverse outcomes after surgery, including wound infection. This is particularly true with reconstructive and aesthetic procedures, but the association is clear with many other types of operations. One recent study of 84 patients undergoing aesthetic abdominoplasty reported the relative risk of smoking on development of infections was 12 (SDC-263). In 425 patients undergoing breast surgery for cancer, the odds ratio for developing infections in smokers versus nonsmokers was 2.95 for light smokers and 3.46 for heavy smokers with an even greater effect on the incidence of skin flap necrosis, OR 6.85 for light smokers and 9.22 for heavy smokers (SDC-264). Another study involving 84 patients showed an odds ratio for infection in smokers versus nonsmokers of 2.1 for major breast operations (SDC-265). Smoking was found to be the only modifiable risk factor for the development of infection (OR = 2.46) in a study of 1505 cases of ventral hernia repair in 13 Veterans Administration Hospitals (SDC-266). Also, in the Veterans Affairs National Surgical Quality Improvement database (NSQIP), involving 7543 patients in 14 medical centers primarily with vascular procedures, smoking was an important factor for the development of infections, particularly in obese patients (OR, 1.5–2.5) (SDC-267). The risk of reamputation was 2.5× higher after leg amputation in smokers than nonsmokers in one study (SDC-268). In 1000 patients undergoing elective cardiac surgery, sternal wound infections occurred with an odds ratio of 1.8 in patients who smoked (SDC-269). These findings were supported by a more recent study involving 7978 cardiac patients where the odds ratio for wound infection was 2.7 in patients who had a smoking history within the past year and 2.6 with a smoking history within the past 2 weeks.[19] Surprisingly, the adjusted odds ratio for wound infection in smokers versus nonsmokers was 16.3 (3.6% vs 0.6%, P = 0.019) in a report of 489 patients undergoing ambulatory surgery (SDC-270). These clinical observations are strongly supported by a randomized clinical study involving 78 healthy volunteers in whom small standardized wounds were made on the buttocks and followed for the development of infection (SDC-271). Wound infections occurred in 12.6% of the wounds in individuals who smoked compared to only 2% in individuals who never smoked. Importantly, infections were significantly fewer in smokers who stopped compared to continued smokers after 4, 8, and 12 weeks of randomization (1.1% vs 21.7%) These studies all show that the risk of having wound infections in smokers compared to nonsmokers is at least doubled, depending upon the procedure, and is even higher involving procedures, which have associated skin flaps or obesity.

Although cessation of smoking seems to reverse the increased susceptibility to wound infections, the best length of time for abstinence still remains to be established. From the existing data, it would seem that cessation of 4 weeks might be sufficient (SDC-271-274).

One of the primary reasons for the adverse effects of smoking on surgical infections is that it clearly decreases oxygen delivery to the wound (SDC-275).


Smoking increases surgical wound infections via several well-established mechanisms including vasoconstriction, which is associated with decreased tissue PO2. Whether high inspired O2 and warming will decrease wound infections in smokers to levels of nonsmokers remains to be studied in prospective trials.


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