Sie sind auf Seite 1von 12

Prevention of Surgical Site Infections in Patients After General & Cardio-thoracic Surgery

Hassam Bashir



Surgical site infections (SSI) are the most common nosocomial infections in the general surgery departments and the second most common in hospitals. SSI are associated with morbidity, long hospitalization and antibiotic treatment, sometimes readmission, reoperation and mortality and associated with high economic costs. The Centers for Disease Control and Prevention (CDC) has developed criteria for defining SSIs, which have become the national standard and are widely used by surveillance and surgical personnel. These criteria define SSIs as infections related to the operative procedure that occur at or near the surgical incision (incisional or organ/space) within 30 days of an operative procedure or within one year if an implant is left in place.

There are controversies in the measures and methods to control and reduce SSI rates. Standard control measures to reduce SSI rates include antimicrobial prophylaxis (timing, selection, duration), hair removal (timing, method, performer), diabetes and insulin therapy, temperature while the operation. Incorrect timing has been proven to increase SSI rates. Antimicrobial therapy should be administered within 60 minutes prior to the surgery to ensure adequate drug tissue levels at the time of initial incision.

Most studies revealed an increased risk for SSIs in patients undergoing preoperative hair removal and a temperature less than 35 [Celsius]. Many other studies have suggested that a preoperative blood glucose level of 200 mg/dL or more (odds ratio


[OR] 10.2) or postoperative hyperglycemia (OR, 2.0) is associated with an increased risk of SSIs.

Our study aimed to evaluate how much attention we make to prevent SSRI. In addition to show real-time data resources that available to document these actions.


Surveyed 107 elective surgeries during the period between 2.2010 to 5.2010. There is 47 (44%) cardio-thoracic surgeries. 60 (56%) general surgeries. The study included 66 men (62%) and 41 women (38%) During this period, data were collected on the type of surgery and date of surgery, age and gender, diabetes, pre-operative antibiotics, antibiotic prophylaxis was given around the operation, timing and duration of antibiotics, the removal of hair (When? By whom? How?) Glucose and insulin treatment (the morning after surgery and two days after surgery), the lowest temperature value and actions to save the body temperature of patients. And sources of information documenting the above variables.

After summarizing the data rates were calculated patients undergo elective surgery who benefit from actions to prevent surgical-site infection. The parameters found were then compared against data in literature. In addition sources of information to prevent surgical site infection were documented. Also the rate of infections in patients who undergoing thoracic and general surgeries. We tried also to examine possible connection between action prevent infection to infections.


There were 107 patients with known infection status at release. Of the 107 patients, 26 (24%; 95% CI: 17-34%) developed an infection. Of the 60 general surgeries, 14 developed a site infection (23%; 95% CI: 13-36%). Of the 47 heart surgeries 12 developed a site infection (26%; 95% CI: 14-40%). More women than men developed and infection. Patients who have diabetes tend to develop more infections. 93% of patients received prophylactic antibiotics according


to the protocol of Hadassah. 92% received the antibiotic at the appropriate time. From those who had a hair removal, 15% hair removed by the protocol. 89% of patients treated with insulin according to the accepted literature, 51% of patients maintained their temperature properly. Most Sources of information regarding the development on infections during hospitalization were nurses. Most of the sources of information about preventative antibiotic treatment were anesthetic report. About 25% of patients developed infection during hospitalization. 14% developed an infection after a month of discharge. Found that Diabetes and stopping a prophylactic antibiotics within 24 hours after surgery are risk factors for infection. In addition, hair removal and maintaining the temp. and the lowest temp. had no effect on the development of infection during the hospitalization, nor the development of infection after 30 days of discharge. Using the logistic regression model shows that diabetes associated with the development of infections, while hair removal is not related (both the nature and timing of hair removal).


Recommendations for prevention of surgical-site infections partially implemented. Despite clear recommendations in the literature and many publications dealt with over the years, and although there is a relative improvement in the activities to prevent infections, it still lacks the attention to infection prevention activities Although there is improvement in maintaining the activity to prevent infections, no formal protocols has made to applicate actions to prevent infection. Also need to give full responsibility for giving AB prophylaxis to anesthesiologist so we can give timely preventive antibiotic (up to one hour before surgery) and inhaled a higher percentage of patients who benefit from this action. Also we should give the decision for remove hair to doctors, while nurses should apply the hair removal not the patient himself, Also we should maintain full documentation of all steps to prevent infections, and build a decent place designated in patient file. In addition to build a computerized file system to prevent infections operations.



1. Consensus paper on the surveillance of surgical wound infections. The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Infect Control Hosp Epidemiol 1992; 13:599.

2. Horan, TC, Gaynes, RP, Martone, WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992;


3. Anonymous. DHHS AND CDC Draft guideline for the prevention of surgical site infection, 1998. Fed Regist 1998; 33167.

4. Hughes, JM, Culver, DH, White, JW, et al. Nosocomial infection surveillance, 1980-1982. MMWR CDC Surveill Summ 1983; 32:1SS.

5. Guinan, JL, McGuckin, M, Nowell, PC. Management of health-care-- associated infections in the oncology patient. Oncology (Williston Park) 2003; 17:415.

6. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986- April 1998, Issued June 1998.

7. Emori, TG, Gaynes, RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 1993; 6:428.



Schaffner, W, Lefkowitz LB, Jr, Goodman, JS, Koenig, MG. Hospital

outbreak of infections with group a streptococci traced to an

asymptomatic anal carrier. N Engl J Med 1969; 280:1224.

9. Stamm, WE, Feeley, JC, Facklam, RR. Wound infections due to group A

streptococcus traced to a vaginal carrier. J Infect Dis 1978; 138:287.

10. Kluytmans, J. Surgical infections including burns. In: Prevention and Control of Nosocomial Infections, Wenzel (Ed), Williams and Wilkins, Baltimore 1997. p.841.

11. Antibiotic prophylaxis in surgery. A national clinical guideline.

Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network

(SIGN); 2000. 36 p. (SIGN publication; no. 45).

12. American Society of Health-System Pharmacists. ASHP therapeutic

guidelines on antimicrobial prophylaxis in surgery. American Journal of

Health System Pharmacy. 1999;56:1839-1888. Available at:

13. Woods RK, Dellinger EP: Current guidelines for antibiotic prophylaxis of

surgical wounds. American Family Physician 1998 Jun; 57(11): 2731-40

14. Carey P, Bohnem JAM, Fletcher R, McManus AT, Solomkin J S, et al.

Antimicrobial prophylaxis for surgical wounds – Guidelines for clinical

care. Arch Surg, 128: 79-88, 1993.


15. Dale W. Bratzler, Peter M. Houck. For the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial Prophylaxis for Surgery:

An Advisory Statement from the National Surgical Infection Prevention Project . Clinical Infectious Diseases 2004;38:1706-1715

16. Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50:161-8.

17. Bratzler, DW, Hunt, DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322.

18. Classen, DC, Evans, RS, Pestotnik, SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326:281.

19. van Kasteren, ME, Manniën, J, Ott, A, et al. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 2007; 44:921.

20. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2009; 7:47.

21. Bratzler, DW, Houck, PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.


22. Dellinger, EP. Prophylactic antibiotics: administration and timing before operation are more important than administration after operation. Clin Infect Dis 2007; 44:928.

23. Zelenitsky, SA, Ariano, RE, Harding, GK, Silverman, RE. Antibiotic pharmacodynamics in surgical prophylaxis: an association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agents Chemother 2002; 46:3026.

24. Goldmann, DA, Hopkins, CC, Karchmer, AW, et al. Cephalothin prophylaxis in cardiac valve surgery. A prospective, double-blind comparison of two-day and six-day regimens. J Thorac Cardiovasc Surg 1977; 73:470.

25. DiPiro, JT, Vallner, JJ, Bowden TA, Jr, et al. Intraoperative serum and tissue activity of cefazolin and cefoxitin. Arch Surg 1985; 120:829.

26. Wong-Beringer, A, Corelli, RL, Schrock, TR, Guglielmo, BJ. Influence of timing of antibiotic administration on tissue concentrations during surgery. Am J Surg 1995; 169:379.

27. DiPiro JT, Cheung RP, Bowden TA Jr, Mansberger JA. Single dose systemic antibiotic prophylaxis of surgical wound infections. American Journal of Surgery 1986;152:552-9.

28. Kriaras I, Michalopoulos A, Michalis A, Palatianos G, Economopoulos G, et al. Antibiotic prophylaxis in cardiac surgery. Journal of Cardiovascular Surgery (Torino) 1997;38:605-10.


29. Mauerhan DR, Nelson CL, Smith DL, Fitzgerald RH Jr, Slama TG, et al. Prophylaxis against infection in total joint arthoplasty -one day of Cefuroxime compared with three days of Cefazolin. Journal of Bone and Joint Surgery, American volume January 1994; (76-A)1:39-45.

30. McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple- dose antimicrobial prophylaxis for major surgery: a systematic review. Australian and New Zealand Journal of Surgery. 1998;68:388-396.

31. Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2009; 7:47.

32. Goldmann, DA, Hopkins, CC, Karchmer, AW, et al. Cephalothin prophylaxis in cardiac valve surgery. A prospective, double-blind comparison of two-day and six-day regimens. J Thorac Cardiovasc Surg 1977; 73:470.

33. McDonald, M, Grabsch, E, Marshall, C, Forbes, A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg 1998; 68:388.

34. Conte JE, Jr, Cohen, SN, Roe, BB, Elashoff, RM. Antibiotic prophylaxis and cardiac surgery. A prospective double-blind comparison of single- dose versus multiple-dose regimens. Ann Intern Med 1972; 76:943.

35. Pollard, JP, Hughes, SP, Scott, JE, et al. Antibiotic prophylaxis in total hip replacement. Br Med J 1979; 1:707.


36. Harbarth, S, Samore, MH, Lichtenberg, D, Carmeli, Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 2000;


37. Mishriki, SF, Law, DJ, Jeffery, PJ. Factors affecting the incidence of postoperative wound infection. J Hosp Infect 1990; 16:223.

38. Seropian, R, Reynolds, BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg 1971; 121:251.

39. Tanner, J, Woodings, D, Moncaster, K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev 2006;


40. Trick, WE, Scheckler, WE, Tokars, JI, et al. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000; 119:108.

41. Latham, R, Lancaster, AD, Covington, JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001;


42. Furnary, AP, Zerr, KJ, Grunkemeier, GL, Starr, A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999; 67:352.


43. Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996;


44. Randomised trial of normothermic versus hypothermic coronary bypass surgery. The Warm Heart Investigators. Lancet 1994; 343:559.

45. Melling, AC, Ali, B, Scott, EM, Leaper, DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001; 358:876.

46. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infection Control and Hospital Epidemiology 1999;20(4):250-78; quiz 279-80.

47. Dale W. Bratzler, Peter M. Houck. For the Surgical Infection Prevention Guidelines Writers Workgroup. Antimicrobial Prophylaxis for Surgery:

An Advisory Statement from the National Surgical Infection Prevention Project . Clinical Infectious Diseases 2004;38:1706-1715

48. Auerbach AD. Chapter 20. Prevention of surgical site infections. In:

Shojania KG, Duncan BW, McDonald KM et al., eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. AHRQ Publication No. 01-E058,


Rockville, MD: Agency for Healthcare Research and Quality. July 2001. pp. 221-244. Available at Accessed December 8, 2003.

49. Auerbach AD. Prevention of surgical site infections. In: Shojania KG, Duncan BW, McDonald KM, et al., eds. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment no. 43. AHRQ publication no. 01-E058. Rockville, MD:

Agency for Healthcare Research and Quality, 20 July 2001:221-44.

50. Furnary AP, Zerr K, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures [with discussion]. Ann Thorac Surg. 1999;67:352-62.

51. Evaluation of antibiotic prophylaxis for surgical site infections at Hadassah hospital - Ein Kerem. Yoni Yousef

52. Preventing Surgical Site Infections From: The Hospitalist, Supplement:

Hospital Medicine and Infectious Diseases Jason Stein, MD, Emory Hospital Medicine Unit, Emory University School of Medicine, Atlanta, GA August 2011

53. Effects of Moderate Intensity Glycemic Control After Cardiac Surgery Gil Leibowitz MD , Ela Raizman BS, MPH, Mayer Brezis MD, Benjamin Glaser MD, Itamar Raz MDand Oz Shapira MD. The Annals of Thoracic Surgery. Volume 90, Issue 6, December 2010, Pages 1825-1832


54. Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection. A Randomized Trial. Thomas Anthony, MD, MSc; Bryce W. Murray, MD; John T. Sum-Ping, MD; Fima Lenkovsky, MD; Vadim D. Vornik, MD; Betty J. Parker, RN; Jackie E. McFarlin, RN, CIC; Kathleen Hartless, RN, CIC; Sergio Huerta, MD. Arch Of Surgery; March 3, 2010.