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Surgical wound infections present a serious hazard to patients and an important legal and economic liability to health care providers. This Guideline furnishes infection control practitioners with several excellent cost-saving concepts and, if implemented, would result in a reduction in the rates of surgical wound infections.
Most surgical wound infections are acquired in the operating room from the patient's own microbial flora. The remainder are acquired mainly from the staff in the operating room during surgery. The inanimate environment (e.g., walls, floors, and surgical instruments) has little relevance to the spread of infection. Because the air is an important route of spread in joint prosthesis operations, the routine use of an ultraclean air system and exhaust-ventilated clothing is frequently recommended. The value of such a system in other types of clean surgery is doubtful, but other measures, such as the following, may provide similar results at less cost: reduction of the number of persons in the operating room; a policy of not opening doors during operations; the use of comfortable, washable, bacteria-impermeable clothing by the operating-room staff; and concentration of the airflow over the operation site rather than over the whole operating room.
We undertook a study of postdischarge infections to assess the reliability of a surgical wound surveillance program in a 930-bed teaching hospital. During a six-month period, a subset of operations performed each day was randomly selected and patients interviewed by telephone one month postsurgery using a standard set of questions. The infection rate for all patients contacted directly postdischarge was 5.4%, whereas the surgical wound infection rate determined for all procedures through the standard hospital program was 1.5%. For day-surgery patients, who are not routinely followed in the hospital surveillance program, 8 (7.8%) of 103 patients contacted had infection. Thus, the overall surgical infection rate determined in this study was over three times higher than that calculated using standard surveillance. A reliable method for identifying postdischarge wound infections is necessary to ensure accurate surgical wound infection rates.
Over a 4-year period 40,923 operations and 44,716 surgical admissions were monitored for both community and hospital onset infections. One thousand eight hundred sixty-five patients had 1966 surgical wound infections and 2056 remote infections including 1652 hospital onset and 404 community onset infections. One thousand one hudnred forty-four patients with multiple infections averaged 40 days in the hospital contrasted with 24 days for 721 patients with a single wound infection. The total excess cost of hospitalization for these patients was $951,150. A statistically significant reduction occurred for urinary tract infections, lower respiratory infections and clean and contaminated surgical wound infections. It is suggested that these are all inter-related and a significant reduction in surgical wound infections can be achieved through control of infections at remote sites, particularly those associated with medical devices. The coagulase positive staphylococcus is still the most important single bacterial species in the primary etiology of surgical wound infections. When the gastrointestinal tract is entered or "supra" infecting organisms appear, gram negative bacteria and mixed gram negative and gram positive infections are dominant. Reduction in remote site infections occurring in surgical patients is necessary to reduce the incidence of surgical wound infections, suggest preventive and control measures, and document the effectiveness of such measures.
The aims of the study were to correlate the laboratory detection rate of wound infections with the actual wound infection rate, and to analyse the bacteriology of these wounds to provide a rationale for antibiotic usage in prophylaxis and treatment of surgical wound infections. The wound infection rate in a general surgical unit was determined using the most comprehensive surveillance available to us and was correlated with the laboratory detection rate. A correlation coefficient of 0.8 was obtained, allowing a reasonable estimation of the actual wound infection rate from laboratory data. Review of the bacteriology of consecutive infected surgical wounds over a 4 year period in a university hospital, revealed that the commonest organisms cultured were Staphylococcus aureus, Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, enterococci and beta-haemolytic streptococci. Methicillin-resistant S. aureus (MRSA) caused 50% of all staphylococcal wound infections. All MRSA isolates were sensitive to fusidic acid and vancomycin. All the non-MRSA isolates of S. aureus were sensitive to cephalexin. Some 89% of E. coli were sensitive to gentamicin, with 93% and 100% sensitive to cefuroxime and ceftriaxone respectively. Klebsiella isolates have shown an increased resistance to aminoglycosides, with a new strain from one patient, isolated in 1990, resistant to penicillins, aminoglycosides and third generation cephalosporins. Pseudomonas spp., enterococci and beta-haemolytic streptococci did not show a change in resistance patterns over the same time period.
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Surgical wound infections due to gram-negative bacilli have been rarely reported following breast implant surgery. From April to November 1989, four patients from one plastic surgeon's practice developed Serratia marcescens surgical wound infection (SWI) following breast reconstruction procedures with implantation of six expandable mammary implants. All six implants were removed for unabated S. marcescens SWI. Symptoms developed 13-161 days (median, 66 days) after surgery. When compared with nonexpandable silicone breast implants used during the period November 1, 1988, to October 31, 1989, expandable implants were associated with a greater risk of S. marcescens SWI (4/10 versus 0/11 patients, p = 0.04). Epidemiologic studies revealed that infection was associated with saline expansion of the implants performed in the surgeon's office. S. marcescens was cultured from a bag of commercial saline used on at least two of the four patients with SWI; the isolate from the saline and the three available patient isolates had identical serotype (O-undetermined:H4) and antimicrobial susceptibility patterns. Review of office procedures revealed that hands were not routinely washed before and aseptic technique was not used during the expansion procedure. Cultures of unopened bags of saline and an unused expandable implant were sterile. We hypothesize that multiple use of saline bags and nonsterile expansion technique extrinsically contaminated saline solutions and resulted in implant and/or surgical site infection. This investigation underscores the importance of avoiding multiple use of solutions intended for single use and of using aseptic technique when manipulating prosthetic devices.
A model of surgical wound infection that uses low inocula of bacteria and closely simulates clinical infection involved inoculating suspensions of Staphylococcus aureus and dextran microbeads into intermuscular sites on the dorsum of guinea pigs, harvesting lesions at 72-96 h, identifying as a positive end point lesions yielding staphylococci on subculture, and using logistic regression for data analysis. Prophylaxis was placebo, ampicillin, or cefazolin, and three representative strains of S. aureus were used. A highly significant correlation (P less than .001) was observed between inoculum sizes and infection rates. Without antimicrobial prophylaxis, ID50 for each strain was less than 10 organisms; with antimicrobials, ID50 was significantly higher. Differences in the virulence of strains and in the efficacy of the antimicrobial regimens also were observed. The model should prove useful for understanding mechanisms of virulence among pathogenic bacteria and for elucidating subtle but important differences in efficacy among antibiotics used in prophylaxis.
Surgical wound infection occurs in fewer than 5% of operations. Nevertheless, it represents the second most common type of hospital-acquired infection and results in increased morbidity and mortality. As with all nosocomial infections, the rate of surgical wound infection increases with age. Patients over 65 years of age run an approximately 15% risk of surgical wound infection. Two-thirds of patients with invasive cancer other than non-melanotic skin cancer are aged 65 years and over. Over half of them are treated surgically for their cancer. Cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly. Using the Foothills Hospital Wound Study Data Base as the sampling frame, we conducted a case-control study of surgical wound infection and cancer among the elderly. Cancer was found not to be a risk factor for surgical wound infection. The results are discussed in relation to the role of immunity in both disorders.
Although surgical wound infections (SWI) following implantation of prosthetic devices can be catastrophic and often require removal of the prosthesis, few studies have identified risk factors for these infections. We conducted a prospective multicenter study to identify risk factors for SWI. Of 561 vascular surgery patients enrolled in the study, 23 (4.1%) developed SWI. Multivariate analysis using logistic regression analyses identified surgery on lower extremities, delayed surgery, diabetes mellitus, past history of vascular surgery, and short antimicrobial prophylaxis (three doses of cefamandole) as independent risk factors for SWI. Consequences of SWI were serious; two (9%) died, 11 (48%) required reoperation, and five (22%) had their prosthesis removed. A risk index was developed using the independent risk factors for SWI identified by logistic regression analyses. When no risk factors were present, no SWI was observed (0 of 100), and the rate of SWI increased from 2.5% when one risk factor was present to 53.8% (7 of 13) when greater than or equal to 4 risk factors were present.
Computer-aided registration of surgical wound infections was started in 1989. During two periods with an interval of one year 98.5% of all patients who had undergone surgery were followed up for four weeks after the operation. The overall infection rate was 12.3% in the first period, and 8.0% in the second. The corresponding figures for clean wounds were 10.7% in the first period and 5.0% in the second. 48% were superficial wound infections. Only 28% of the infections were detected before the patients were discharged from hospital. Registration is strongly recommended as a tool for surveillance and control of surgical wound infections.
OBJECTIVES: Describe an outbreak of surgical wound infections associated with total hip arthroplasty; identify risk factors for surgical wound infection during the pre-outbreak and outbreak periods. SETTING: A 100-bed hospital. From May 1 to September 30, 1988, 7 of 15 patients who underwent total hip arthroplasty developed surgical wound infections from Staphylococcus aureus (5), Enterobacter cloacae (1), beta-hemolytic streptococci (1), enterococci (1), coagulase-negative staphylococci (1), and Escherichia coli (1) (attack rate = 46.7%). DESIGN: Retrospective cohort studies comparing surgical wound infection rates by patient- and procedure-related risk factors during the pre-outbreak and outbreak periods were conducted. Drop plate quantitative air culturing was conducted in 10 consecutive total hip arthroplasties in the subsequent 6 months. RESULTS: Rates of surgical wound infection were surgically higher for arthroplasties in which no intraoperative prophylactic antimicrobials were given (44% versus 8%, relative risk [RR] = 5.4, p = .01), or in which the posterior approach (20% versus 3%, RR = 6.7, p = .04) or a specific prosthesis (39% versus 5%, RR = 6.3, p = 0.01) was used. The surgical wound infection rate was highest when one circulating nurse, Nurse A, assisted (47% versus 4%, RR = 12.8, p less than .001). Logistic regression analysis identified use of the posterior approach (RR = 1.8, p = .04) and Nurse A's participation (RR = 5.0, p less than .001) as independent risk factors for surgical wound infection. Interviews of the nursing supervisor indicated that Nurse A had recurrent dermatitis on her hands. During 6 months following Nurse A's reassignment, the rate declined significantly (from 7/15 to 0/10, p = .01). Drop plate culturing yielded 2 to 10 colonies per plate of organisms that did not match outbreak organisms. CONCLUSIONS: Outbreaks associated with personnel generally involve only 1 species. In this outbreak, Nurse A (possibly because of her dermatitis), technique, the posterior approach, and/or other undetermined factors were the primary predictors of surgical wound infection.
OBJECTIVE: To determine the clean surgical wound infection rate for breast procedures and the risk factors predisposing patients to these infections. DESIGN: A survey study. SETTING: Oncology center. PATIENTS: A consecutive sample of adult female patients who underwent surgical breast procedures for suspected carcinoma of the breast. Patients undergoing excisional biopsy, lumpectomy, or mastectomy from January 1985 to January 1987 were included in the study. INTERVENTION: Clean surgical wound infection rates were derived overall and for each procedure type. The medical records of all patients were then reviewed to extract data on patient characteristics and operative information in order to assess the risk factors for infection. RESULTS: Among the breast procedures performed on 448 patients, the overall clean surgical wound infection rate was 8.7% (39/448). The clean surgical wound infection rate for each procedure type was as follows: biopsy 2.3%, lumpectomy 6.6%, and mastectomy 19%. In addition to the type of procedure, factors significantly (p less than .05) associated with the development of clean surgical wound infection in the univariate analysis included: presence of surgical drains (p less than .01); closed suction drainage (odds ratio [OR] = 16.5, 95% confidence interval [CI95] = 5.0-54.7); location of the drain (OR = 3.3, CI95 = 1.7-6.6); prolonged preoperative stay (OR = 1.2, CI95 = 1.0-1.5); length of surgery (OR = 2.2, CI95 = 1.7-3.0); and greater mean age (OR = 1.6, CI95 = 1.2-2.1). CONCLUSION: Clean surgical wound infections are not uncommon in patients undergoing breast procedures. Factors relating to both the patient and operative techniques contribute to the clean surgical wound infection rate. Further consideration should be given to perioperative antibiotic prophylaxis for selected breast procedures, and the role of surgical drains should be reassessed.
A Surgical Wound Infection (SWI) Task Force was convened by The Society for Hospital Epidemiology of America (SHEA) to evaluate how SWI surveillance should be done and to identify where more information is needed. The Task Force reached consensus in the following areas. The Centers for Disease Control (CDC) definitions of SWI should be used for routine surveillance because of their current widespread acceptance and reproducibility. The CDC definitions have been clarified in an accompanying article ("Report From the CDC"). Direct observation of wounds and traditional infection control surveillance techniques are acceptable methods of case finding for hospitalized patients. The optimal method for case finding postdischarge or after outpatient surgery is unknown at this time. SWI rates should be stratified by surgical wound class plus a measure of patient susceptibility to infection, such as the American Society of Anesthesiology (ASA) class, and duration of surgery. Surgeon-specific SWI rates should be calculated and reported to individual surgeons.
A comprehensive review of the factors responsible for postoperative wound sepsis is discussed, along with the experimental basis for the use of prophylatic antibiotics and a review of the results of the use of systemic and topical antibiotics on the incidence of surgical wound infections. Based on the data presented, suggestions are made which should minimize the development of postoperative wound infections.
Approximately 35,000 Staphylococcus aureus surgical wound infections occur annually in the United States. To investigate why S aureus causes infection despite the perioperative administration of cephalosporins, we compared 35 methicillin-susceptible isolates recovered from deep wound infections that complicated cefazolin prophylaxis (18 of 1650 patients) and cefamandole prophylaxis (17 of 3702 patients) with 64 colonizing isolates from presurgical patients. Compared with both colonizing and cefamandole-associated isolates, S aureus isolates from cefazolin-associated infections were more resistant to cefazolin by specialized assays. Staphylococcus aureus isolates that produced the A and C variants of staphylococcal beta-lactamase were associated with infections following cefazolin and cefamandole prophylaxis, respectively. These isolates hydrolyze the respective cephalosporins rapidly, suggesting that staphylococcal survival after perioperative prophylaxis may be mediated by in vivo degradation of the prophylactically administered cephalosporin. These data indicate that some S aureus wound infections occur because of deficiencies in antimicrobial effectiveness that are not detectable by routine susceptibility tests. This finding has important implications for the therapy and prevention of S aureus infection.
Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.