Surgical site and other acquired perioperative infections

Introduction

When a patient awakens from anesthesia after surgery, they usually look at their wound site to see how big the incisional bandage is. Usually, the patient and their family are relieved to hear that the operation was a success and believe the whole ordeal is over, even though patients are generally informed before surgery that unexpected events, including infections, can develop during their recovery, even after discharge. Such healthcare-associated infections (HAIs) are a considerable burden to the patient and the healthcare delivery system. These events alter a patient's expected course delaying full recovery and increasing the risk of undesirable outcomes such as death and disability. In this chapter, we describe HAIs with a focus on surgical site infections (SSIs) and outline the methods that help reduce their occurrence.

HAIs can be acquired within any healthcare setting, even in medical offices, laboratories, and ambulatory sites. However, the perioperative setting presents a particularly high-risk environment given the metabolic derangements and damage resulting from the surgical manipulation of tissues, alteration of tissue perfusion, and other transient disruptions of homeostasis. HAIs jeopardize surgical outcomes and increase a patient's length of stay, morbidity, and mortality resulting in billions of dollars in additional healthcare costs. There are multiple opportunities along the health delivery process where healthcare teams can intervene to reduce HAI and improve the outcomes. All interprofessional healthcare team members have a role to play in infection prevention. For a surgical case, practices can be instituted before, during, and after surgery to reduce the risks of infections.

Increasingly, the rates of postsurgical infections at a hospital are accessible by the general public, and, often, detailed data are available for individual procedures and surgeons. These and other types of clinical quality data, such as patient mortality and patient satisfaction, may be used to determine payment for services and for accreditation decisions. Guidelines reflecting best practices to reduce infections have been established, and healthcare agencies promote and monitor the implementation of such practices. For example, the Centers for Medicare and Medicaid Services (CMS) tracks the rates of major complications after common surgical procedures ( https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures ). In the United States, validated national standards of care and treatment processes, or Core Quality Measures, reflect the quality of care a hospital provides and allow stakeholders in the healthcare system to assess and compare provider organizations to reduce complications and improve patient outcomes. Compliance with Core Measures demonstrates the commitment of healthcare organizations to achieve optimal outcomes.

Definition of healthcare-associated infections

Common HAIs associated with perioperative care include postoperative pneumonia (including VAP), catheter-related bloodstream infection (CRBSI), catheter-associated urinary tract infections (CAUTIs), Clostridium difficile infections (CDIs), and SSIs, discussed below. In all cases, strict handwashing between patients and appropriate prophylactic antibiotics help decrease the transfer of microorganisms to patients. To be considered an HAI, the infection must occur after 48 h of initial admission, and the identification of the infection should not be present at the time of admission. VAP is determined to be an acquired condition if it occurs 48–72 h after endotracheal intubation. Table 12.1 outlines the criteria for an infection to qualify as HAI.

Surgical site infections

SSIs are infections at or near surgical incisions within 30 days of an operative procedure and account for 15% of all nosocomial infections. They are the leading type of HAIs occurring between 2% and 5% of patients having surgery and are associated with a 2- to 11-fold increase in mortality. They increase the cost of healthcare by $20,842 per admission leading to over a billion dollars yearly in direct expenditures and nearly another billion in readmission costs. The Centers for Disease Control (CDC) of the United States estimated that over 110,000 SSIs are associated with inpatient surgeries annually, accounting for 20% of all HAIs, resulting in an estimated cost of $3.3 billion. Rates of SSIs appear to be decreasing modestly due to the considerable focus on eliminating preventable patient harm by provider organizations ( https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf ).

The surveillance period for SSIs begins on the day of surgery and lasts either 30 or 90 days, depending on the type of surgery. The CDC defines two major SSI categories: incisional and organ space infections ( Table 12.2 ). Incisional SSIs can be “ superficial” involving only skin and subcutaneous tissue, and “deep,” involving underlying soft tissues such as fascia or muscle.