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Surgical Site Infections
Abstract
Surgical site infections (SSIs), previously known as wound infections , remain one of the most common adverse events that occur with hospitalized surgical patients or after outpatient surgical procedures, despite many advances in preventive techniques. A 2015 report from the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC) documents SSI as accounting for 16% of all healthcare-associated infections (HAIs) among hospitalized patients. Of 100,000 HAIs reported in 1 year, deaths followed SSI in 8000 cases. The incidence of SSI after a surgical procedure is highly variable, depending on the type of operation being done and the underlying risk factors of the patient, but the average across the United States is estimated to be 2% to 3% of all procedures. Length of stay and associated costs are dramatically increased when an SSI develops.
Clinical Vignette
A 54-year-old woman, otherwise healthy, underwent a low anterior resection through a lower midline incision with a stapled, end to end anastomosis (EEA) colorectal anastomosis for a suspicious polyp at a prior rectal cancer site. She had preoperative bowel prep with oral antibiotics and appropriate parenteral prophylactic antibiotics. Everything went well, and she had a smooth recovery and was discharged on the third postoperative day, tolerating a diet and with an intact incision.
Eleven days postop she called with concerns for feeling feverish and noting redness around the lower portion of her incision for 1½ inches. She was seen in the office the next day and found to have inflamed skin with some swelling around the lower portion of her incision, which was tender to palpation. Her temperature was 38°, with a heart rate of 90. Probing the wound revealed a 3 cm deep cavity, which extended 6 cm cephalad. The overlying skin was opened and dressed with gauze, and she was sent home with instructions for dressing changes.
Eleven days later, she was seen with no fever, wound clean with granulation tissue, and fascia intact.
Two weeks after the last visit her wound was clean and skin was approximated with Steri Strips.
A month later, she was seen with a well-healed incision without any inflammation.
Definitions
SSSIs are divided into three categories according to the anatomic extent of the infection at the time of diagnosis: superficial incisional SSI, deep incisional SSI, or organ or organ space SSI ( Table 52.1 ). A superficial incisional SSI occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision. In addition, the patient has at least one of the following:
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Purulent drainage from the superficial incision
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Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
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At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and the superficial incision is deliberately opened by the surgeon and is culture positive if cultured or is not cultured (a culture-negative finding does not meet the definition for SSI)
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A diagnosis of superficial incisional infection that has been made by the surgeon or attending physician
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Table 52.1
Summary of Surgical Site Infections
| Category | Onset | Characteristics | Criteria |
|---|---|---|---|
| Superficial incisional SSI | Within 30 days of operation | Involves skin and subcutaneous tissue of the incision only |
|
| Deep incisional SSI | Within 30 days of operation if no implant left in place Within 90 days of operation if implant left in place |
Involves deep soft tissues (e.g., fascia or muscle layers of the incision) |
|
| Organ or organ space SSI | Within 30 days of operation if no implant left in place Within 90 days of operation if implant left in place |
Involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure | See chapters in this Surgical Infections Section for organ or organ space SSIs involving specific anatomic sites. |
SSI, Surgical site infections.
There are two specific types of superficial SSI. A primary superficial SSI is one that occurs in the primary incision in a patient who has had an operation with one or more incisions. A secondary superficial SSI is one that occurs in the secondary incision in a patient who has had an operation with more than one incision. An example would be the donor site in the leg for a patient who has had a coronary artery bypass with a vein graft taken from the leg.
A deep incisional SSI is one that develops within 30 days of the operative procedure if no implant was left in place during the operation or within 90 days if an implant was left and the infection appears to be related to the operative procedure. By definition, a deep incisional SSI involves deep soft tissues (e.g., fascia or muscle layers of the incision) and the patient has purulent drainage or the deep incision spontaneously dehisces or is deliberately opened by the surgeon and is cultured or, if not cultured, the patient has fever (temperature >38°C) or localized pain or tenderness (a culture-negative finding does not meet the definition for SSI). As with superficial incisional SSI, deep incisional SSI can be either primary or secondary.
An organ or organ space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure. When an organ or organ space SSI is reported, the specific anatomic site involved is also reported. Thus an intra-abdominal abscess, an empyema, a mediastinal infection, or a joint space infection after an operation at one of those sites would be reported as an organ or organ space SSI in the abdomen, chest, mediastinum, or joint space. By definition, an organ or organ space SSI occurs within 30 days of the operation if no implant was left or within 90 days if an implant was involved. Most organ or organ space SSIs are covered in other chapters of this book and so will not be dealt with further here.
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