Surgical Site Infection Prevention

Surgical site infection (SSI) is one of the most common and devastating complications of orthopaedic surgical procedures. The Centers for Disease Control and Prevention (CDC) estimates that 22% of all healthcare-associated infections are SSIs. More than 290,000 SSIs occur annually in the United States, resulting in $1 billion to $10 billion in direct and indirect medical costs. In 2002, there were more than 43 million procedures in the United States, of which more than 600,000 included open reduction and internal fixation.

Although advances in infection prevention have occurred over recent years, SSIs remain a substantial cause of morbidity and mortality. Patients with SSIs are 60% more likely to spend time in an intensive care unit, twice as likely to die, and five times more likely to be readmitted compared with patients without an SSI. In surgical patients with an SSI who died, 89% of the deaths were attributable to the infection. These statistics translate not only into significant losses for the individual patient but also a dramatic burden on societal healthcare costs as a whole.

The pathogens involved in SSIs did not change much between 1986 and 1996. Staphylococcus species, including Staphylococcus aureus, are the leading nosocomial pathogens in hospitals worldwide. Coagulase-negative staphylococci, Enterococcus species, and Escherichia coli are also commonly isolated pathogens. Gram-negative organisms are reported to account for approximately 30% of SSIs in cardiac surgery and total joint arthroplasty. More recently there has also been an increase in infections related to antimicrobial-resistant pathogens such as methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci, both of which colonize the skin and are spread by direct contact. In the United States, it has been estimated that 94,360 invasive MRSA infections occurred in 2005 and that 86% of these were healthcare associated. The death rate from MRSA is 2.5 times greater than from nonresistant S. aureus, and more than 18,000 MRSA deaths were documented in 2005.

In the United States, prevention and treatment of these infections has become a national priority. The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee that consists of 14 external infection control experts. The HICPAC works together with the CDC and the Secretary of the Department of Health and Human Services to formulate best practices for healthcare-associated infection prevention, control, and surveillance. The CDC's National Nosocomial Infections Surveillance System (NNIS), established in 1970, monitors nosocomial infection trends.

In an effort to make evidence-based recommendations on infection prevention, the CDC published the “Guideline for Prevention of Surgical Site Infection, 1999.” In 2002, the CDC collaborated with the Centers for Medicare and Medicaid Services (CMS) to implement the Surgical Site Infection Project. The goal of the project was to decrease mortality and morbidity associated with SSIs by promoting appropriate prophylactic antibiotic choice and timing. Effective July 1, 2006, The Joint Commission expanded the Surgical Site Infection Project to the Surgical Care Improvement Project (SCIP). SCIP is a partnership of many organizations dedicated to improving surgical care. The American Academy of Orthopaedic Surgeons (AAOS) is one of more than 30 organizations represented. The goal of SCIP was to reduce the incidence of surgical complications nationally by 25% by the year 2010. Some of the SCIP target areas pertinent to orthopaedic surgery are shown in Box 77.1 .

Defining Surgical Site Infections

The National Nosocomial Infections Surveillance System (NNIS) has provided standardized surveillance criteria for defining SSIs ( Fig. 77.1 and Box 77.2 ). These definitions, applied consistently by surveillance personnel, have become a national standard. SSIs are classified as superficial if they involve only the skin and subcutaneous tissue and deep if the infection is within the fascia or muscle. Organ/space SSIs involve any part of the anatomy other than incised body wall layers that were manipulated during surgery. Septic arthritis, septic bursitis, diskitis, epidural abscess, and osteomyelitis are considered organ/space SSIs. Infection occurs within 30 days after the procedure if no implant is left in place or within 1 year if an implant is in place and the infection appears to be related to the operation.

Box 77.2

Criteria for Defining a Surgical Site Infection (SSI)

Superficial Incisional SSI

Infection occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following:

• 1.

  Purulent drainage, with or without laboratory confirmation, from the superficial incision

• 2.

  Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision

• 3.

  At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by surgeon unless the incision is culture negative

• 4.

  Diagnosis of superficial incisional SSI by the surgeon or attending physician

Do not report the following conditions as SSI:

• 1.

  Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration)

• 2.

  Infection of an episiotomy or newborn circumcision site

• 3.

  Infected burn wound

• 4.

  Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI )

Note : Specific criteria are used for identifying infected episiotomy and circumcision sites and burn wounds.

Deep Incisional SSI

Infection occurs within 30 days after the operation if no implant *

* National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or hip prosthesis) that is permanently placed in a patient during surgery.

is left in place or within 1 year if the implant is in place and the infection appears to be related to the operation and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following:

• 1.

  Purulent drainage from the deep incision but not from the organ/space component of the surgical site

• 2.

  A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38°C), localized pain, or tenderness unless the site is culture negative

• 3.

  An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination

• 4.

  Diagnosis of a deep incisional SSI by a surgeon or attending physician

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