SURGICAL SITE INFECTIONS Surgical site infections (SSIs) are those that present in any location along the

surgical tract after a surgical procedure. In 1992 the Surgical Wound Infection Task Force published a new set of definitions for wound infections that included changing the term to SSI. Unlike surgical wound infections, SSIs involve postoperative infections presenting at any level (incisional or deep) of a specific procedure. SSIs are divided into incisional superficial (skin, subcutaneous tissue), incisional deep (fascial plane and muscles), and organ/space related (anatomic location of the procedure itself). Examples of organ/space SSIs would include intraabdominal abscesses, empyema, or mediastinitis.[1] SSI is the most common nosocomial infection in our population, reaching 38% of all infections in surgical patients. By definition it can present anytime from 0 to 30 days after the operation or up to 1 year after a procedure that has involved the implantation of a foreign material (such as mesh, vascular graft, or prosthetic joint). Incisional infections are the most common accounting for 60% to 80% of all SSIs and have a better prognosis than organ/space-related SSIs, the latter accounting for 93% of SSI-related mortalities.[1] [2] [3] The microbiology of SSI is related to the bacterial flora present in the exposed anatomic area of a particular procedure and has been relatively fixed during the last 30 years as shown by the National Nosocomial Infection Surveillance System (NNIS) established by the Centers for Disease Control and Prevention (CDC). This study has shown that Staphylococcus aureus remains the most common pathogen of SSI followed by Staphylococcus coagulase negative, Enterococcus, and Escherichia coli. However for clean-contaminated and contaminated procedures, E. coli and other Enterobacteriaceae are the most common cause of SSI. Also in recent years some emerging organisms have become more common. Vancomycin-resistant enterococcus (VRE) and gram-negative bacilli with unusual patterns of resistance have been isolated more frequently. Of particular interest is the growing frequency of Candida spp as cause for SSI and surgical infections in general.[2] Understanding the microbiology of SSI is important to guide initial empiric therapy of infections in a specific patient, as well as for identification of outbreaks and for strategies in the management of prophylactic antibiotics as discussed later in this chapter. Causes and Risk Factors Three areas have been identified as risk factors for SSI: bacterial factors, local wound factors, and patient factors ( Table 121 ). The interaction between these three is what determines the risk of SSI as a complication in surgery. Most of these factors have been shown to be associated with SSI; however it has been difficult to show an independent association between each one of these and the presence of SSI.

Bacterial factors include virulence and bacterial load in the surgical site. The development of infection is affected by the toxins produced by the microorganism and the microorganisms ability to resist phagocytes and intracellular destruction. Several bacterial species have surface components that contribute to their pathogenicity by inhibiting phagocytosis (e.g., the capsules of Klebsiella and Streptococcus pneumoniae, slime of Staphylococcus coagulase negative). Gram-negative bacteria have surface components (endotoxin or

lipopolysaccharide) that are toxic, and others, such as certain strains of clostridia and streptococci, produce powerful exotoxins. These exotoxins permit streptococci and clostridia to establish invasive infection after smaller inocula than other pathogens and to evolve much more rapidly. Thus, although most wound infections do not become evident clinically for 5 days or longer after the operation, infections due to streptococci or clostridia may become severe within 24 hours. Studies of traumatic wounds in healthy subjects have shown that bacterial contamination with more than 105 organisms frequently causes infection, whereas contamination with less than 105 organisms usually does not. The normal defense mechanisms therefore are of great importance in preventing infection at its inception, but wound infection is inevitable if the bacterial inoculum is sufficiently large. This observation led, in the 1990s, to the wound classification system in which wounds are classified and presumed to have different number and type of bacteria according to the anatomic areas entered and to the aseptic and antiseptic techniques used ( Table 122 ).

Length of preoperative stay, remote site infection at the time of operation, and duration of the procedure have also been associated with an increased SSI rate.[4] Preoperative shaving has been shown to increase SSI after clean procedures. This practice increases the infection rate about 100% compared with removing the hair by clippers at the time of the procedure or not removing it at all, probably secondary to bacterial growth in microscopic cuts. Therefore, the patient should not be shaved before an operation. Extensive removal of hair is not needed, and any that is done should be performed by electric clippers with disposable heads at the time of the procedure and in a manner that does not traumatize the skin.[5] Local wound factors are related to the fact that surgeons break basic barrier defense mechanisms such as skin and gastrointestinal mucosa while performing a procedure. In doing so there are specific factors associated with an increased rate of infection. Good surgical technique is the best way to avoid SSI while managing tissues (local wound) in the most appropriate manner and using sutures, drains, and foreign bodies only with adequate indications. Patient-related factors include age, immunosuppression, steroids, malignancy, obesity, perioperative transfusions, cigarette smoking, diabetes, other preexisting illness and malnutrition, among others. It is hard to perform a study in which independent association with SSI can be proven while controlling for all other factors; however, patient-related factors seem to play an important role in SSI, and preventive measures are starting to focus on manipulating these, as discussed later in this section. Recent data suggest that maintaining normothermia and delivering an inspired fraction of oxygen (FiO2 ) of 80% or more in the OR and postanesthesia care unit will reduce the rate of SSI by improving oxygen tension and white blood cell function in the surgical incision. Also, data suggest that control of glucose levels in the perioperative period and up to 48 hours later in both diabetic and nondiabetic patients can reduce the rates of SSI. SSI Risk Scores SSI risk has traditionally been correlated to wound class. The accepted range of infection rate has been clean, 1% to 5%; clean-contaminated, 3% to 11%; contaminated, 10% to 17%; and dirty, higher than 27%. Wound class as discussed earlier is a significant risk factor for SSI; however, it assesses only the bacterial factors related to wound infection, and it is an imprecise method of including different types of procedures and different kinds of patients into one same category.

More recently the NNIS score, published by Culver and associates in 1991,[2] includes additional factors that have an independent relation with SSI ( Table 123 ). The NNIS score includes the wound class, the American Society of Anesthesiologists score, and the duration of the procedure measured by the duration of the operation compared with national averages for the same operation. This differentiates risk of SSI more accurately than the prior wound classification system used alone ( Table 124 ).[2] [10]

Prevention Understanding risk factors and preventive measures should promote better control with lower infection rates. Three primary measures have proven to have a significant impact on SSI. First, the aseptic and antiseptic technique introduced by Lister reduced SSI markedly. The second is the proper use of prophylactic antibiotics, and the third, the implementation of surveillance programs. Tcnica assptica e antisptica, atb profiltico e programas de vigilncia. Microorganisms are part of the human body microenvironment, and they will always be present. Even clean wounds have small numbers of bacteria present at the end of the operation. Most early prevention measures implemented were focused on controlling the bacterial factors for wound infections. In recent years research has focused on manipulating host (patient) factors to assist the body in dealing with fixed bacterial factors (assuming all preventive measures have been applied appropriately). The future in the control of infection will focus on patient factors and the bodys ability to counteract the obligatory presence of microorganisms. Os mecanismos de preveno devem se focar nos fatores relacionados ao pct, para ajudar na relao com os fatores bacterianos, pois a presena de microorganismos obrigatria. Preventive measures can be also classified according to the three determinants of wound infection and to the timing at which they are implemented (preoperatively, intraoperatively, postoperatively) ( Table 125 ).

Microorganism Related Microorganisms causing SSI can be either exogenous or endogenous. Exogenous microorganisms come from the operating team or from the environment around the surgical site (such as OR, equipment, air, and water). Endogenous microorganisms come either from the bacteria present in the patient at the surgical site or from bacteria present at a different location (e.g., remote site infection, nasal colonization). Two primary measures exist to control the bacterial load in the surgical site: aseptic and antiseptic methods and antimicrobial prophylaxis.[14] Aseptic and Antiseptic Methods Specific environmental and architectural characteristics of the OR help reduce the bacterial load in the OR itself, although it has not been proven to decrease the incidence of SSI except in refined clean procedures such as joint replacement. Basic principles include size of the OR, air management (filtered, flow, positive pressure toward the outside, and air cycles/hour), equipment handling (disinfection and cleansing), and traffic rules. All OR personnel should wear clean scrubs, caps, and masks, and traffic in and out of the OR should be minimized. Exogenous sources of bacteria causing SSI are rare when standard measures are followed and is only important in cases of outbreaks, such as those that follow failure of sterilization procedures or are traced to OR personnel who shed bacteria. Specific air-filtering mechanisms and other high-technology measures for environmental control in the OR play a significant role in wound infection control only in clean cases in which prostheses are implanted. However, a minimum of basic traffic, environment, and OR behavior rules should be followed by staff in the surgical pool as part of a discipline that keeps the team aware of potential causes of infections in surgical patients. Surgical site preparation, however, is an important measure in preventing SSI. Preoperative showers the night before surgery with chlorhexidine have not proven to affect SSI, although they reduce the bacterial colony count in skin areas. The CDC recommends its use, and it is reasonable to use particularly in patients that have been in the hospital for a few days and in those in whom a SSI will carry significant morbidity (cardiac, vascular, and prostheses procedures). Skin preparation of the surgical site should be done using a germicidal antiseptic such as tincture of iodine, povidone-iodine, or chlorhexidine. An alternate preparation is the use of antimicrobial incise drapes applied to the entire operative area. Traditionally the surgical team has scrubbed their hands and forearms for at least 5 minutes the first time in the day and for 3 minutes every consecutive time. Popular antiseptics used are povidone-iodine and chlorhexidine. Recent data have shown that the use of alcoholic hand-rub solutions are as effective while being faster and kinder to the skin of the surgical team. The use of sterile drapes and gowns is a way of maintaining every surface in contact with the surgical site as sterile as possible. As many as 90% of an operative team puncture their gloves during a prolonged operation. The risk increases with time as does the risk for contamination of the surgical site if the glove is not changed at the moment of puncture. The use of double-gloving is becoming a popular practice that avoids contamination of the wound as well as exposure to blood by the surgical team. Double-gloving is recommended for all surgical procedures.[15] Instruments that will be in contact with the surgical site should be sterilized in a standard fashion and

protocols for flashsterilization and/or emergent sterilization must be well established to ensure the sterility of instruments and implants. Antimicrobial Prophylaxis Systemic antimicrobial prophylaxis is a potentially powerful preventive measure for SSI that is frequently delivered in an ineffective manner due more to the lack of a reliable process in the hospital and OR than to lack of understanding. Experience has shown that the effectiveness of antibiotic prophylaxis depends on an organized system to ensure its delivery in an effective manner. If a system is not in place, the results are haphazard failures. Recent national surveys have documented suboptimal prophylactic antibiotic use in 40% to 50% of operative procedures. It is clear that the administration of therapeutic doses of antimicrobial agents can prevent infection in wounds contaminated by bacteria sensitive to the agents. The decision to use prophylactic antibiotic therapy, however, must be based on balancing possible benefit against possible adverse effects. Indiscriminate use of antibiotics should be discouraged because it may lead to emergence of antibiotic-resistant strains of organisms or serious hypersensitivity reactions. In particular, prolonged use of prophylactic antibiotics may also mask the signs of established infections, making diagnosis more difficult, and causes an increase in the number of resistant pathogens recovered from surgical patients. Prophylactic systemic antibiotics are not indicated for patients undergoing low-risk, straightforward, clean surgical operations in which no obvious bacterial contamination or insertion of a foreign body has occurred. When the incidence of wound infections is less than 1% and the consequences of SSI are not severe, the potential for reducing this low infection rate does not justify the expense and side effects of antibiotic administration. Prophylactic antibiotic therapy is no substitute for careful surgical technique using established surgical principles, and its indiscriminate or general use is not in the best interest of the patient. Antibiotic agents can be used effectively only as adjuncts to adequate surgery. In several clinical situations the administration of prophylactic systemic antibiotic therapy is usually beneficial. These situations almost always involve a brief period of contamination by organisms that can be predicted with reasonable accuracy. As examples, prophylactic systemic antibiotics reduce infection with clinical benefit in the following circumstances: 1. High-risk gastroduodenal proceduresthese include operations for gastric cancer, ulcer, obstruction, or bleeding; those operations when gastric acid production has been suppressed effectively; and gastric operations for morbid obesity 2. High-risk biliary proceduresthese include operations in patients older than 60 years of age; those for acute inflammation, common duct stones, or jaundice; and those with prior biliary tract operations or endoscopic biliary manipulation 3. Resection and anastomosis of the colon or small intestine (see later) 4. Cardiac procedures through a median sternotomy 5. Vascular surgery of the lower extremities or abdominal aorta 6. Aputation of an extremity with impaired blood supply, particularly in the presence of a current or recent ischemic ulcer 7. Vaginal or abdominal hysterectomy 8. Primary cesarean section 9. Operations entering the oral-pharyngeal cavity 10. Craniotomy 11. Implantation of any permanent prosthetic material 12. Any wound with known gross bacterial contamination

13. Accidental wounds with heavy contamination and tissue damage. In such instances, the antibiotic should be given intravenously as soon as possible after injury. The two beststudied situations are penetrating abdominal injuries and open fractures. 14. Injuries prone to clostridial infection because of extensive devitalization of muscle, heavy contamination, and/or impairment of blood supply 15. Presence of preexisting valvular heart damage, to prevent the development of bacterial endocarditis Whether or not prophylactic antibiotics should be given for clean operations not involving the implantation of prosthetic materials has been controversial. A well-designed trial demonstrated reduction in infection risk when patients undergoing breast procedures or groin hernia repairs received prophylactic antibiotics compared to placebo.[17] However, these procedures are not universally considered valid indications for prophylaxis. Some have proposed that such clean operations with one or more NNIS risk points should be considered for prophylactic antibiotic administration. The administration of oral nonabsorbable antibiotics to suppress both aerobic and anaerobic intestinal bacteria before scheduled operations on the colon has also been successful in controlled trials. Neomycin plus erythromycin given only on the day before surgery, 19, 18, and 9 hours before the scheduled start of the procedure, is the most well-established combination at present. Neomycin and metronidazole is also an effective combination. Thorough mechanical cleansing of the intestinal tract is an important component of the oral regimen.[19] Several reports demonstrate a reduced infection rate with the combination of oral nonabsorbable and intravenous antibiotics, and this is the most common practice among colorectal surgeons in the United States. Prophylactic antibiotic therapy is clearly more effective when begun preoperatively and continued through the intraoperative period, with the aim of achieving therapeutic blood levels throughout the operative period. This produces therapeutic levels of the antibiotic agents at the operative site in any seromas and hematomas that may develop. Antibiotics started as late as 1 to 2 hours after bacterial contamination are markedly less effective, and it is completely without value to start prophylactic antibiotics after the wound is closed. Failure of prophylactic antibiotic agents occurs in part through a neglect of the importance of the timing and dosage of these agents, which are critical determinants. For most patients with elective surgery, the first dose of prophylactic antibiotics should be given intravenously at the time anesthesia is induced. It is unnecessary and may be detrimental to start them more than 1 hour preoperatively, and it is unnecessary to give them after the patient leaves the OR. A single dose, depending on the drug used and length of operation, is often sufficient. For operations that are prolonged, the prophylactic agent chosen should be given in repeated doses at intervals of one to two half-lives for the drug being used. It is never indicated to give prophylactic antibiotic coverage for more than 12 hours for a planned operation. There is no evidence to support the practice of continuing prophylactic antibiotics until central lines, drains, and/or chest tubes are removed. There is evidence that this practice increases the recovery of resistant bacteria. Many patients fail to receive needed prophylactic antibiotics because the system for their administration is complex at the time of multiple events just before a major operation. This problem has been made worse by the trend of admitting patients directly to the OR for planned operations, which intensifies the pressures to accomplish a large number of procedures during a short interval before the operation. The possibility that prophylactic antibiotics will be unintentionally omitted can be minimized by establishing a system with a checklist. One member of the operative team (usually the preoperative nurse or a member of the anesthesia team) should be responsible for initialing a portion of the operative record that states either that the patient received indicated prophylactic antibiotics or that the surgeon has determined that antibiotics are not indicated for the procedure. Many antibiotics effectively reduce the rate of postoperative SSIs when used appropriately for indicated procedures. No antibiotic has been reliably superior to another when each possessed a similar and appropriate antibacterial spectrum. The most important determinant is whether the planned procedure is expected to enter parts of the body known to harbor

obligate colonic anaerobic bacteria (Bacteroides species). If anaerobic flora are anticipated, such as during operations on the colon or distal ileum or during appendectomy, then an agent effective against Bacteroides species, such as cefotetan, must be used. Cefoxitin is an alternative with a dramatically shorter half-life. If anaerobic flora are not expected, cefazolin is the prophylactic drug of choice. For patients who are allergic to cephalosporins, clindamycin, or in settings where methicillinresistant S. aureus (MRSA) is common, vancomycin can be used. The prophylactic use of vancomycin should be minimized as much as possible to reduce environmental pressures favoring the emergence of VREs and staphylococci. If an intestinal procedure is planned in such an allergic patient, a regimen with activity against gram-negative rods and activity against anaerobes, such as an aminoglycoside combined with clindamycin or metronidazole, or aztreonam combined with clindamycin, must be used. The use of topical antibiotics often effectively diminishes the incidence of infection in contaminated wounds. However, the combination of topical agents and parenteral agents is not more effective than either one alone, and topical agents alone are inferior to parenteral agents in complex gastric procedures. As a general rule, topical agents do not cause any harm if one adheres to the following rules: (1) do not use any agent in wounds or in the abdomen that would not be suitable for parenteral administration; and (2) do not use more of the agent than would be acceptable for parenteral administration. In considering the amount used, any drug being given parenterally must be added to the amount being placed in the wound. Topical agents used for burn wounds (discussed elsewhere) may be used in large open wounds in selected patients. Prophylactic antibiotic therapy is generally ineffective in clinical situations in which continuing contamination is likely to occur. Examples are as follows: (1) in patients with tracheostomies or tracheal intubation to prevent pulmonary infections; (2) in patients with indwelling urinary catheters; (3) in patients with indwelling central venous lines; (4) in patients with wound or chest drains; and (5) in most open wounds, including burn wounds. Local Wound Related Most of the preventive measures related to the local wound are determined by the good judgment and surgical technique of the surgeon. Intraoperative measures include appropriate handling of tissues and assurance of satisfactory final vascular supply but with adequate control of bleeding to prevent hematomas/seromas. Complete dbridement of necrotic tissues and removal of unnecessary foreign bodies as well as avoiding the placement of foreign bodies in clean-contaminated, contaminated, or dirty cases is recommended. Monofilament sutures have proven in experimental studies to have a lower rate of SSI. Sutures are foreign bodies that should be used only when required. Suture closure of dead space has not been shown to prevent SSI. Large potential dead spaces can be treated with the use of closed-suction systems for short periods, since these provide a route for bacteria to reach the wounds and cause SSI. Open drainage systems (e.g., Penrose) increase rather than decrease infections in surgical wounds and should be avoided unless used to drain wounds that are already infected. In heavily contaminated wounds or in wounds in which all the foreign bodies or devitalized tissues cannot be satisfactorily removed, delayed primary closure minimizes the development of serious infection in most instances. With this technique, the subcutaneous tissues and skin are left open and dressed loosely with gauze after fascial closure. The number of phagocytic cells at the wound edges progressively increases to reach a peak about 5 days after the injury. Capillary budding is intense at this time, and closure can usually be accomplished successfully even with heavy bacterial contamination because phagocytic cells can be delivered to the site in large numbers. Experiments have shown that the number of organisms required to initiate an infection in a surgical incision progressively increases as the interval of healing increases, up to the 5th postoperative day. Finally, adequate dressing of the closed wound isolates it from the outside environment. Providing an appropriate dressing for 48 to 72 hours can decrease wound contamination. However, dressings after this period increase the subsequent bacterial count by altering the microenvironment underneath in the healing wound. Patient Related

Host resistance is abnormal in a variety of systemic conditions and diseases, including leukemia, diabetes mellitus, uremia, prematurity, burn or traumatic injury, advanced malignancy, old age, obesity, malnutrition, and several diseases of inherited immunodeficiency. With surgical patients who have these or similar problems, extra precautions should be taken to prevent the development of wound infections, including correction or control of the underlying defect whenever possible. Malnutrition and low albumin levels are associated with an increased rate of SSI. Optimizing nutritional status prior to surgery and early in the postoperative periods with specific immunonutrition (arginine, nucleotides, omega-3 fatty acids) formulas may decrease SSI in upper gastrointestinal tract cancer patients. Recent studies have also demonstrated that maintaining a higher partial pressure of oxygen by delivering higher FiO2 with adequate fluid resuscitation is associated with decreased rate of SSI. The presumed mechanism is through more available oxygen for white blood cells to kill bacteria present in the wound at the time of the operation. Preoperative warming was also shown in two recent prospective, randomized, controlled trials to reduce SSI rates. Other studies have shown that increasing temperature results in increased perfusion and increased oxygen delivery to the incision. Finally, in critically ill patients, aggressive perioperative insulin therapy with the use of insulin drips to maintain glucose levels between 80 and 110 mg/dL was associated with decreased mortality in this set of patients. Other studies of cardiac and gastrointestinal surgery patients have demonstrated an increased rate of SSI when perioperative blood glucose levels exceeded 200 mg/dL whether the patients were diabetic or not. Although SSIs are still the most common nosocomial infection in surgical patients, knowledge regarding risk factors as well as methods for prevention are rapidly growing. Present and future investigations are focusing on the patients ability to overcome the presence of microorganisms and avoid infection. It is the modern surgeons responsibility to be up to date with this information and to implement all known and proven measures that reduce the presence of this complication. Wound infection surveillance systems have proven to be an important measure in controlling SSI rates, and perhaps this is achieved by permanent and continuous awareness from surgeons and surgical teams of the risk and the measures that can be used to avoid this common complication.[12] Surveillance of SSI should include a determination for each SSI of whether or not all accepted preventive measures were provided for that patient and procedure. If they were not, the SSI can be classified as potentially preventable. If all appropriate preventive measures were provided, then the SSI is apparently unpreventable. The goal of surgical practice and surveillance should be to have no potentially preventable SSI. As our knowledge regarding SSI prevention increases, the definition of potentially preventable can expand.