Beruflich Dokumente
Kultur Dokumente
1 g 1 hr before procedure
or
Azithromycin or clarithromycin, 500 mg1 hr
before procedure
Parenteral
Clindamycin, 600 mg IV within 30 min before
procedure
or
Cefazolin or ceftriaxone, 1 g IM or IV within
30 min before procedure
Infected gastrointestinal or
genitourinary operation; abscess
drainage
Oral
Amoxicillin, 2 g 1 hr before procedure
Parenteral
Ampicillin, 2 g IM or IV within 30 min
before procedure; if risk of endocarditis is
considered high, add gentamicin,
1.5 mg/kg (to maximum of 120 mg) IM or
IV 30 min before procedure
Parenteral
Vancomycin, 1 g IV infused slowly over 1 hr,
beginning 1 hr before procedure; if risk of
endocarditis is considered high, add
gentamicin, 1.5 mg/kg (to maximum of
120 mg) IM or IV 30 min before procedure
*Pediatric dosages are as follows: oral amoxicillin, 50 mg/kg; oral or parenteral clindamycin, 20 mg/kg; oral cephalexin or cefadroxil, 50 mg/kg; oral azithromycin
or clarithromycin, 15 mg/kg; parenteral ampicillin, 50 mg/kg; parenteral cefazolin, 25 mg/kg; parenteral gentamicin, 2 mg/kg. The total pediatric dose should not exceed
the total adult dose.
Patients with a history of immediate-type sensitivity to penicillin should not receive these agents.
High-risk patients should also receive ampicillin, 1 g IM or IV, or amoxicillin, 1 g PO, 6 hours after the procedure.
nated and become infected in the postoperative period.
27
Accordingly, use of a dry dressing for 24 hours seems
prudent.
nac1cniaL inoicn1ics
Not only is the size of
the bacterial inoculum
important; the bacterial
properties of virulence
and pathogenicity are
also signicant. The
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
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The preoperative hospital stay has frequently been found
to make an important contribution to wound infection rates.
13
The usual explanation is that during this stay, either more
endogenous bacteria are present or commensal ora is
replaced by hospital ora. More likely, the patients clinical
picture is a complex one, often entailing exhaustive workup
of more than one organ system, various complications, and a
degree of illness that radically changes the hosts ability to
deal with an inoculum, however small. Therefore, multiple
factors combine to transform the hospitalized preoperative
patient into a susceptible host. Same-day admission
should eliminate any bacterial impact associated with the
preoperative hospital stay.
Bacteria with multiple antibiotic resistance (e.g.,
methicillin-resistant S. aureus [MRSA], Staphylococcus epider-
midis, and vancomycin-resistant enterococci [VRE]) can
be associated with signicant SSI problems. In particular,
staphylococci, with their natural virulence, present an
important hazard if inappropriate prophylaxis is used.
Many surgeons consider it inappropriate or unnecessary to
obtain good culture and sensitivity data on SSIs; instead of
conducting sensitivity testing, they simply drain infected
wounds, believing that the wounds will heal. However, there
have been a number of reports of SSIs caused by unusual
organisms
24,27,28
; these ndings underscore the usefulness of
culturing pus or uid when an infection is being drained.
SSIs caused by antibiotic-resistant organisms or unusual
pathogens call for specic prophylaxis, perhaps other infec-
tion control efforts, and, if the problem persists, a search for
a possible carrier or a common source.
2224,27,28
scnccoNs aNu nac1cnia
The surgeons peri-
operative rituals are
designed to reduce or
eliminate bacteria from
the operative eld.
Many old habits are
obsolete [see 1:8 Prepa-
ration of the Operating
Room and Discussion,
Hand Washing, below].
Nonetheless, it is clear that surgeons can inuence SSI rates.
14
The refusal to use delayed primary closure or secondary clo-
sure is an example. Careful attention to the concepts of asep-
sis and antisepsis in the preparation and conduct of the oper-
ation is important. Although no single step in the ritual of
preparing a patient for the operative procedure is indispens-
able, it is likely that certain critical standards of behavior must
be maintained to achieve good results.
The measurement and publication of data about individu-
als or hospitals with high SSI rates have been associated with
a diminution of those rates [see Table 6].
13,14,29
It is uncertain
by what process the diffusion of these data relates to the
observed improvements. Although surveillance has unpleas-
ant connotations, it provides objective data that individual
surgeons are often too busy to acquire but that can contribute
to improved patient care. For example, such data can
be useful in identifying problems (e.g., the presence of
MRSA, a high SSI incidence, or clusters), maintaining
quality assurance, and allowing comparison with accepted
standards.
Environment: Local
Factors
Local factors inu-
ence SSI development
because they affect the
size of the bacterial
inoculum that is required
Preoperative Preparation of the Operative Site
The sole reason for preparing the patient's skin before an opera-
tion is to reduce the risk of wound infection. A preoperative
antiseptic bath is not necessary for most surgical patients, but
their personal hygiene must be assessed and preoperative
cleanliness established. Multiple preoperative baths may pre-
vent postoperative infection in selected patient groups, such as
those who carry Staphylococcus aureus on their skin or who
have infectious lesions. Chlorhexidine gluconate is the recom-
mended agent for such baths.
120
Hair should not be removed from the operative site unless it
physically interferes with accurate anatomic approximation of
the wound edges.
15
If hair must be removed, it should be clip-
ped in the OR.
15
Shaving hair from the operative site, particul-
arly on the evening before operation or immediately before
wound incision in the OR, increases the risk of wound infection.
Depilatories are not recommended, because they cause
serious irritation and rashes in a significant number of patients,
especially when used near the eyes and the genitalia.
121
In emergency procedures, obvious dirt, grime, and dried
blood should be mechanically cleansed from the operative
site by using sufficient friction. In one study, cleansing of con-
taminated wounds by means of ultrasound dbridement was
compared with highpressure irrigation and soaking. Both
ultrasound dbridement and high-pressure irrigation were
also effective in reducing the wound infection rate in expe-
rimental wounds contaminated with a subinfective dose of
S. aureus and colloidal clay.
122
For nonemergency procedures, the necessary reduction in
microorganisms can be achieved by using povidoneiodine
(10% available povidoneiodine and 1% available iodine) or
chlorhexidine gluconate both for mechanical cleansing of the
intertriginous folds and the umbilicus and for painting the
operative site. Which skin antiseptic is optimal is unclear.
The best option appears to be chlorhexidine gluconate or an
iodophor.
123
The patient should be assessed for evidence of
sensitivity to the antiseptic (particularly if the agent contains
iodine) to minimize the risk of an allergic reaction. What some
patients report as iodine allergies are actually burns. Iodine
in alcohol or in water is associated with an increased risk of
skin irritation,
96
particularly at the edges of the operative field,
where the iodine concentrates as the alcohol evaporates.
Iodine should therefore be removed after sufficient contact time
with the skin, especially at the edges. Iodophors do not irritate
the skin and thus need not be removed.
Table 5 Effect of Surveillance and Feedback on Wound
Infection Rates in Two Hospitals
29
Period 1 Period 2*
Hospital A
Number of wounds 1,500 1,447
Wound infection rate 8.4% 3.7%
Hospital B
Number of wounds 1,746 1,939
Wound infection rate 5.7% 3.7%
*Periods 1 and 2 were separated by an interval during which feedback on
wound infection rates was analyzed.
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
INFECTION 10
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to produce an infection: in a susceptible wound, a smaller
inoculum produces infection [see Figure 2].
1nc scnccoNs iNrLccNcc
Most of the local factors that make a surgical site favorable
to bacteria are under the control of the surgeon. Although
Halsted usually receives, deservedly so, the credit for having
established the importance of technical excellence in the OR
in preventing infection, individual surgeons in the distant past
achieved remarkable results by careful attention to cleanliness
and technique.
30
The halstedian principles dealt with hemo-
stasis, sharp dissection, ne sutures, anatomic dissection, and
the gentle handling of tissues. Mass ligatures, large or braided
nonabsorbable sutures, necrotic tissue, and the creation of
hematomas or seromas must be avoided, and foreign materi-
als must be judiciously used because these techniques and
materials change the size of the inoculum required to initiate
an infectious process. Logarithmically fewer bacteria are
required to produce infection in the presence of a foreign
body (e.g., suture, graft, metal, or pacemaker) or necrotic
tissue (e.g., that caused by gross hemostasis or injudicious
use of electrocautery devices).
The differences in inoculum required to produce wound
infections can be seen in a model in which the two variables
are the wound hematocrit and the presence of an antibiotic
[see Figure 3]. In the absence of an antibiotic and in the
presence of wound uid with a hematocrit of more than 8%,
10 bacteria yield a wound infection rate of 20%. In a techni-
cally good wound with no antibiotic, however, 1,000 bacteria
produce a wound infection rate of 20%.
12
In the presence of
an antibiotic, 10
5
to 10
6
bacteria are required.
Drains
The use of drains varies widely and is very subjective. All
surgeons are certain that they understand when to use a
drain. However, certain points are worth noting. It is now
recognized that a simple Penrose drain may function as a
drainage route but is also an access route by which pathogens
can reach the patient.
31
It is important that the operative
site not be drained through the wound. The use of a closed
suction drain reduces the potential for contamination and
infection.
Many operations on the gastrointestinal (GI) tract can be
performed safely without employing prophylactic drainage.
32
A review and meta-analysis from 2004 concluded that
(1) after hepatic, colonic, or rectal resection with primary
anastomosis and after appendectomy for any stage of appen-
dicitis, drains should be omitted (recommendation grade A),
Table 6 Determinants of Infection and Factors that Inuence Wound Infection Rates
29
Variable Determinant of Infection
Bacteria Wound Environment (Local
Factors)
Host Defense Mechanisms (Systemic
Factors)
Bacterial numbers in wound a
Potential contamination a
Preoperative shave a
Presence of three or more diagnoses c
Age b c
Duration of operation a b c
Abdominal operation
Relative value unit > 10
Emergency surgery
a b c
ASA class III, IV, or V c
O
2
tension b
Glucose control c
Normothermia b c
Shock b c
Smoking b c
Diabetes
10
b c
Dyspnea
10
c
Steroid use
10
b c
Serum albumin < 3.5 g/L
10
c
Age g40
10
c
Radiotherapy
10
c
> 2 alcoholic drinks
10
c
ASA = American Society of Anesthesiologists.
2008 BC Decker Inc ACS Surgery: Principles and Practice
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INFECTION 11
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and (2) after esophageal resection and total gastrectomy,
drains should be used (recommendation grade D). Additional
randomized, controlled trials will be required to determine
the value of prophylactic drainage for other GI procedures,
especially those involving the upper GI tract.
Duration of Operation
In most studies, contamination certainly increases with
time (see above).
6,11,13
Wound edges can dry out, become
macerated, or in other ways be made more susceptible to
infection (i.e., requiring fewer bacteria for development of
infection). Speed and poor technique are not suitable
approaches; expeditious operation is appropriate.
Electrocautery
The use of electrocautery devices (but not the harmonic
scalpel) has been clearly associated with an increase in the
incidence of supercial SSIs. However, when such devices
are properly used to provide pinpoint coagulation (for which
the bleeding vessels are best held by ne forceps) or to divide
tissues under tension, there is minimal tissue destruction, no
charring, and no change in the wound infection rate.
31
ia1icN1 rac1ons
Local Blood Flow
Local perfusion can
greatly inuence the
devel opment of infec-
tion, as is seen most
easily in the tendency of the patient with peripheral vascular
disease to acquire infection of an extremity. As a local prob-
lem, inadequate perfusion reduces the number of bacteria
required for infection, in part because inadequate perfusion
leads to decreased tissue levels of oxygen. Shock, by reducing
local perfusion, also greatly enhances susceptibility to infec-
tion. Fewer organisms are required to produce infection
during or immediately after shock [see Figure 4].
To counter these effects, the arterial oxygen tension
(P
a
O
2
) must be translated into an adequate subcutaneous
oxygen level (determined by measuring transcutaneous
oxygen tension)
33
; this, together with adequate perfusion, will
provide local protection by increasing the number of bacteria
required to produce infection. Provision of supplemental
oxygen in the perioperative period may lead to a reduced SSI
rate, probably as a consequence of increased tissue oxygen
tension,
34
although the value of this practice has been ques-
tioned.
35
If the patient is not intubated, a mask, not nasal
prongs, is required.
36
Barrier Function
Inadequate perfusion may also affect the function of other
organs, and the resulting dysfunction will, in turn, inuence
the patients susceptibility to infection. For example,
ischemia-reperfusion injury to the intestinal tract is a frequent
consequence of hypovolemic shock and bloodstream infec-
tion. Inadequate perfusion of the GI tract may also occur
during states of uid and electrolyte imbalance or when
cardiac output is marginal. In experimental studies, altered
blood ow has been found to be associated with the break-
down of bowel barrier functionthat is, the inability of the
intestinal tract to prevent bacteria, their toxins, or both from
moving from the gut lumen into tissue at a rate too fast
to permit clearance by the usual protective mechanisms. A
variety of experimental approaches aimed at enhancing bowel
barrier function have been studied; at present, however,
the most clinically applicable method of bowel protection is
initiation of enteral feeding (even if the quantity of nutrients
provided does not satisfy all the nutrient requirements)
and administration of the amino acid glutamine [see 8:22
Nutritional Support]. Glutamine is a specic fuel for entero-
cytes and colonocytes and has been found to aid recovery of
damaged intestinal mucosa and enhance barrier function
when administered either enterally or parenterally.
Advanced Age
Aging is associated with structural and functional changes
that render the skin and subcutaneous tissues more suscep-
tible to infection. These changes are immutable; however,
they must be evaluated in advance and addressed by excellent
surgical technique and, on occasion, prophylactic antibiotics
[see Sidebar Antibiotic Prophylaxis of Infection]. SSI rates
increase with aging until the age of 65 years, after which
point, the incidence appears to decline.
37
Host Defense
Mechanisms
The systemic re sponse
is designed to control
and eradicate infection.
Many factors can inhibit
systemic host defense
mechanisms; some are related to the surgical disease and
others to the patients underlying disease or diseases and the
events surrounding the operation.
scnccoN-ncLa1cu rac1ons
There are a limited number of ways in which the surgeon
can improve a patients systemic responses to surgery.
Nevertheless, when appropriate, attempts should be made
to modify the host. The surgeon and the operation are
both capable of reducing immunologic efcacy; hence, the
operative procedure should be carried out in as judicious
a manner as possible. Minimal blood loss, avoidance of
shock, and maintenance of blood volume, tissue perfusion,
and tissue oxygenation will minimize trauma and will reduce
the secondary, unintended immunologic effects of major
procedures.
Diabetes has long been recognized as a risk factor for infec-
tion and for SSI in particular. Three studies from the past
decade demonstrated the importance of glucose control for
reducing SSI rates in both diabetic and nondiabetic patients
who underwent operation,
38,39
as well as in critically ill inten-
sive care unit patients.
40
Glucose control is required through-
out the entire perioperative period. The benecial effect
appears to lie in the enhancement of host defenses. The sur-
gical team must also ensure maintenance of adequate tissue
oxygen tension
33,34
and maintenance of normothermia.
41
When abnormalities in host defenses are secondary to
surgical disease, the timing of the operation is crucial to out-
come. With acute and subacute inammatory processes, early
2008 BC Decker Inc ACS Surgery: Principles and Practice
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INFECTION 12
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operation helps restore normal immune function. Deferral of
denitive therapy frequently compounds problems.
ia1icN1 rac1ons
Surgeons have always
known that the patient
is a signicant variable
in the outcome of opera-
tion. Various clinical
states are associated with altered resistance to infection. In
all patients, but particularly those at high risk, SSI creates
not only wound complications but also signicant morbidity
(e.g., reoperation, incisional hernia, secondary infection,
impaired mobility, increased hospitalization, delayed reha-
bilitation, or permanent disability) and occasional mortality.
23
SENIC has proposed that the risk of wound infection
be assessed not only in terms of probability of contamination
but also in relation to host factors.
6,7,9
According to this
study, patients most clearly at risk for wound infection are
those with three or more concomitant diagnoses; other
patients who are clearly at risk are those undergoing a clean-
contaminated or contaminated abdominal procedure and
those undergoing any procedure expected to last longer than
2 hours. These last two risk groups are affected by a bacterial
component, but all those patients who are undergoing major
abdominal procedures or lengthy operations generally have a
signicant primary pathologic condition and are usually older,
with an increased frequency of concomitant conditions. The
NNIS system uses most of the same concepts but expresses
them differently. In the NNIS study, host factors in the large
study are evaluated in terms of the ASA score. The duration
of the operation is measured differently as well, with a lengthy
operation being dened by the NNIS as one that is at or
above the 75th percentile for operating time. Bacterial
contamination remains a risk factor, but the operative site is
eliminated.
8
Shock has an inuence on the incidence of wound infection
[see Figure 4]. This inuence is most obvious in cases of
trauma, but there are signicant implications for all patients
in regard to maintenance of blood volume, hemostasis, and
oxygen-carrying capacity. The effect of shock on the risk of
infection appears to be not only immediate (i.e., its effect on
local perfusion) but also late because systemic responses are
blunted as local factors return to normal.
Advanced age, transfusion, and the use of steroids and
other immunosuppressive drugs, including chemotherapeutic
agents, are associated with an increased risk of SSI.
42,43
Often,
these factors cannot be altered; however, the proper choice of
operation, the appropriate use of prophylaxis, and meticulous
surgical technique can reduce the risk of such infection by
maintaining patient homeostasis, reducing the size of any
infecting microbial inoculum, and creating a wound that is
likely to heal primarily.
Smoking is associated with a striking increase in SSI inci-
dence. As little as 1 week of abstinence from smoking will
make a positive difference.
44
Pharmacologic therapy can affect host response as well.
Nonsteroidal anti-inammatory drugs that attenuate the
production of certain eicosanoids can greatly alter the adverse
effects of infection by modifying fever and cardiovascular
effects. Operative procedures involving inhalational anes-
thetics result in an immediate rise in plasma cortisol
con centrations. The steroid response and the associated
immunomodulation can be modied by using high epidural
anesthesia as the method of choice; pituitary adrenal
Figure 4 Animals exposed to
hemorrhagic shock followed by
resuscitation show an early decreased
resistance to wound infection. There
is also a persistent inuence of shock
on the development of wound
infection at different times of
inoculation after shock. The impor-
tance of inoculum size (10
6
/mL to
10
8
/mL) and the effect of antibiotic on
infection rates are evident at all times
of inoculation.
109
2008 BC Decker Inc ACS Surgery: Principles and Practice
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INFECTION 13
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activation will be greatly attenuated. Some drugs that inhibit
steroid elaboration (e.g., etomidate) have also been shown to
be capable of modifying perioperative immune responses.
Using this vast database of NSQIP, Neumayer and colleagues
integrated most of these variables into an expanded risk
assessment [see Table 6].
10
aNcs1ncsioLocis1-
ncLa1cu rac1ons
A 2000 commentary
in The Lancet by Donal
Buggy con sidered the
question of whether
anesthetic management
could inuence surgical wound healing.
45
In addition to the
surgeon- and patient-related factors already discussed
(see above), Buggy cogently identied a number of
anesthesiologist-related factors that could contribute to better
wound healing and reduced wound infection. Some of these
factors (e.g., pain control, epidural anesthesia, and autolo-
gous transfusion) are unproven but nonetheless make sense
and should certainly be tested. Others (e.g., tissue perfusion,
intravascular volume, andsignicantlymaintenance of
normal perioperative body temperature) have undergone
formal evaluation. Very good studies have shown that dra-
matic reductions in SSI rates can be achieved through careful
avoidance of hypothermia.
41,46
Patient-controlled analgesia
pumps are known to be associated with increased SSI rates,
through a mechanism that is currently unknown.
47
Infection
control practices are required of all practitioners; contamina-
tion of anesthetic drugs by bacteria has resulted in numerous
small outbreaks of SSI.
48,49
As modern surgical practice has evolved and the variable
of bacterial contamination has come to be generally well
managed, the importance of all members of the surgical team
in the prevention of SSI has become increasingly apparent.
The crux of Buggys commentary may be expressed as
follows: details make a difference, and all of the participants
in a patients surgical journey can contribute to a continuing
decrease in SSI. It is a systems issue.
iN1ccna1ioN or uc1cn:iNaN1s
As operative infection rates slowly fall, despite the perfor-
mance of increasingly complex operations in patients at
greater risk, surgeons are approaching the control of infection
with a broader view than simply that of asepsis and antisepsis.
This new, broader view must take into account many vari-
ables, of which some have no relation to bacteria, but all play
a role in SSI [see Table 6 and Figure 1].
To estimate risk, one must integrate the various determi-
nants of infection in such a way that they can be applied to
patient care. Much of this exercise is vague. In reality,
the day-to-day practice of surgery includes a risk assessment
that is essentially a form of logistic regression, although
not recognized as such. Each surgeons assessment of the
probability of whether an SSI will occur takes into account
the determining variables:
Probability of SSI =
x + a (bacteria) + b (environment: local factors)
+ c (host defense mechanisms: systemic factors)
Discussion
aN1inio1ic inoinvLaxis or ssi
It is difcult to understand why antibiotics have not always
prevented SSI successfully. Certainly, surgeons were quick
to appreciate the possibilities of antibiotics; nevertheless,
the efcacy of antibiotic prophylaxis was not proved until the
late 1960s.
12
Studies before then had major design aws
principally, the administration of the antibiotic some time
after the start of the operation, often in the recovery room.
The failure of studies to demonstrate efcacy and the
occasional nding that prophylactic antibiotics worsened
rather than improved outcome led in the late 1950s to pro-
found skepticism about prophylactic antibiotic use in any
operation.
The principal reason for the apparent inefcacy was inad-
equate understanding of the biology of SSIs. Fruitful study
of antibiotics and how they should be used began after phys-
iologic groundwork established the importance of local blood
ow, maintenance of local immune defenses, adjuvants, and
local and systemic perfusion.
50
The key antibiotic study, which was conducted in guinea
pigs, unequivocally proved the following about antibiotics
51
:
1. They are most effective when given before inoculation of
bacteria.
2. They are ineffective if given 3 hours after inoculation.
3. They are of intermediate effectiveness when given between
these times [see Figure 5].
Although efcacy with a complicated regimen was demon-
strated in 1964,
52
the correct approach was not dened until
1969.
12
Established by these studies are the philosophical and
practical bases of the principles of antibiotic prophylaxis of
5
M
e
a
n
2
4
-
H
o
u
r
L
e
s
i
o
n
D
i
a
m
e
t
e
r
(
m
m
)
Lesion Age at Time of Penicillin Injection (hr)
1 0 1 2 3 4 5 6
10
Staphylococcal Lesions
Staphylococcal Lesions + Antibiotic
Killed Staphylococcal Lesions
Figure 5 In a pioneer study of antibiotic prophylaxis,
51
the
diameter of lesions induced by staphylococcal inoculation
24 hours earlier was observed to be critically affected by the
timing of penicillin administration with respect to bacterial
inoculation.
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
INFECTION 14
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SSI in all surgical arenas
12,51
: that prophylactic antibiotics
must be given preoperatively within 2 hours of the incision,
in full dosage, parenterally, and for a very limited period.
These principles remain essentially unchanged despite minor
modications from innumerable subsequent studies.
5357
Prophylaxis for colorectal operations is discussed elsewhere
[see Infection Prevention in Bowel Surgery, below].
Principles of Patient Selection
Patients must be selected for prophylaxis on the basis of
either their risk for SSI or the cost to their health if an SSI
develops (e.g., after implantation of a cardiac valve or another
prosthesis). The most important criterion is the degree
of bacterial contamination expected to occur during the
operation. The traditional classication of such contamina-
tion was dened in 1964 by the historic National Academy of
SciencesNational Research Council study.
5
The important
features of the classication are its simplicity, ease of under-
standing, ease of coding, and reliability. Classication is
dependent on only one variablethe bacterial inoculum
and the effects of this variable are now controllable by
antimicrobial prophylaxis. Advances in operative technique,
general care, antibiotic use, anesthesia, and surveillance have
reduced SSI rates in all categories that were established by
this classication.
6,13,14,51
In 1960, after years of negative studies, it was said, Nearly
all surgeons now agree that the routine use of prophylaxis in
clean operations is unnecessary and undesirable.
58
Since
then, much has changed: there are now many clean opera-
tions for which no competent surgeon would omit the use of
prophylactic antibiotics, particularly as procedures become
increasingly complex and prosthetic materials are used in
patients who are older, sicker, or immunocompromised.
A separate risk assessment that integrates host and bacte-
rial variables (i.e., whether the operation is dirty or contami-
nated, is longer than 2 hours, or is an abdominal procedure
and whether the patient has three or more concomitant
diagnoses) segregates more effectively those patients who are
prone to an increased incidence of SSI [see Integration of
Determinants of Infection, below]. This approach enables the
surgeon to identify those patients who are likely to require
preventive measures, particularly in clean cases, in which
antibiotics would normally not be used.
6
The prototypical clean operation is an inguinal hernia
repair. Technical approaches have changed dramatically over
the past 10 years, and most primary and recurrent hernias are
now treated with a tension-free mesh-based repair. The use
of antibiotics has become controversial. In the era of repairs
under tension, there was some evidence to suggest that a
perioperative antibiotic (in a single preoperative dose) was
benecial.
59
Current studies, however, do not support antibi-
otic use in tension-free mesh-based inguinal hernia repairs.
60,61
On the other hand, if surveillance indicates that there is a
local or regional problem
62
with SSI after hernia surgery, anti-
biotic prophylaxis (again in the form of a single preoperative
dose) is appropriate. Without signicantly more supportive
data, prophylaxis for clean cases cannot be recommended
unless specic risk factors are present.
Data suggest that prophylactic use of antibiotics may con-
tribute to secondary Clostridium difcile disease; accordingly,
caution should be exercised when widening the indications
for prophylaxis is under consideration.
63
If local results are
poor, surgical practice should be reassessed before antibiotics
are prescribed.
Antibiotic Selection and Administration
When antibiotics are given more than 2 hours before oper-
ation, the risk of infection is increased.
53,55
IV administration
in the OR or the preanesthetic room guarantees appropriate
levels at the time of incision. The organisms likely to be
present dictate the choice of antibiotic for prophylaxis. The
cephalosporins are ideally suited to prophylaxis: their features
include a broad spectrum of activity, an excellent ratio of
therapeutic to toxic dosages, a low rate of allergic responses,
ease of administration, and attractive cost advantages. Mild
allergic reactions to penicillin are not contraindications for
the use of a cephalosporin.
Physicians like new drugs and often tend to prescribe
newer, more expensive antibiotics for simple tasks. First-
generation cephalosporins (e.g., cefazolin) are ideal agents for
prophylaxis. Third-generation cephalosporins are not: they
cost more, are not more effective, and promote emergence of
resistant strains.
64,65
The most important rst-generation cephalosporin for sur-
gical patients continues to be cefazolin. Administered IV in
the OR at the time of skin incision, it provides adequate tissue
levels throughout most of the operation. A second dose
administered in the OR after 3 hours will be benecial if the
procedure lasts longer than that. Data on all operative site
infections are imprecise, but SSIs can clearly be reduced by
this regimen. No data suggest that further doses are required
for prophylaxis.
Fortunately, cefazolin is effective against both gram-
positive and gram-negative bacteria of importance, unless
signicant anaerobic organisms are encountered. The signi-
cance of anaerobic ora has been disputed, but for elective
colorectal surgery,
66
abdominal trauma,
67,68
appendicitis,
69
or
other circumstances in which penicillin-resistant anaerobic
bacteria are likely to be encountered, coverage against both
aerobic and anaerobic gram-negative organisms is strongly
recommended and supported by the data.
Despite several decades of studies, prophylaxis is not always
properly implemented.
53,55,69,70
Unfortunately, didactic educa-
tion is not always the best way to change behavior. Preprinted
order forms
71
and a reminder sticker from the pharmacy
72
have proved to be effective methods of ensuring correct use.
The commonly heard decision This case was tough; lets
give an antibiotic for 3 to 5 days has no data to support
it and should be abandoned. The extended duration is
associated with an increase in MRSA SSIs.
73
Differentiation
between prophylaxis and therapeusis is important. A thera-
peutic course for perforated diverticulitis or other types of
peritoneal infection is appropriate. Data on casual contami-
nation associated with trauma or with operative procedures
suggest that 24 hours of prophylaxis or less is quite
adequate.
7476
Mounting evidence suggests that a single
preoperative dose is good care and that additional doses are
not required.
Trauma Patients
The efcacy of antibiotic administration on arrival in the
emergency department as an integral part of resuscitation has
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been clearly demonstrated.
77
The most common regimens
have been (1) a combination of an aminoglycoside and
clindamycin and (2) cefoxitin alone. These two regimens
or variations thereof have been compared in a number of
studies.
41,68,76,77
They appear to be equally effective, and either
regimen can be recommended with condence. For prophy-
laxis, there appears to be a trend toward using a single drug:
cefoxitin or cefotetan.
56
If therapy is required because of
either a delay in surgery, terrible injury, or prolonged shock,
the combination of an agent that is effective against anaer-
obes with an aminoglycoside seems to be favored. Because
aminoglycosides are nephrotoxic, they must be used with care
in the presence of shock.
In many of the trauma studies just cited, antibiotic prophy-
laxis lasted for 48 hours or longer. Subsequent studies, how-
ever, indicated that prophylaxis lasting less than 24 hours is
appropriate.
75,76,78
Single-dose prophylaxis is appropriate for
patients with closed fractures.
79
Complications
Complications of antibiotic prophylaxis are few. Although
data linking prophylaxis to the development of resistant
organisms are meager, resistant microbes have developed in
every other situation in which antibiotics have been used, and
it is reasonable to expect that prophylaxis in any ecosystem
will have the same result, particularly if selection of patients
is poor, if prophylaxis lasts too long, or if too many late-
generation agents are used.
A rare but important complication of antibiotic use is
pseudomembranous enterocolitis, which is induced most
commonly by clindamycin, the cephalosporins, and ampicil-
lin [see 8:16 Nosocomial Infection].
63
The common denomina-
tor among different cases of pseudomembranous enterocolitis
is hard to identify. Diarrhea and fever can develop after
administration of single doses of prophylactic antibiotics. The
condition is rare, but difculties occur because of failure to
make a rapid diagnosis.
Current Issues
The most signicant questions concerning prophylaxis of
SSIs already have been answered.
The problem has been the implementation of the strategies
known to work. Table 7 outlines seven measures known with
hard data to be important in the reduction of SSI. These
management approaches are integrated into the Surgical Care
Improvement Project
80
and the Surgical Infection Prevention
Project.
81
Single hospitals have used these criteria in ongoing
quality improvement programs.
82
More impressive is the
collaborative reported by Dellinger and colleagues in which
56 hospitals tracked, monitored, and internally fed back the
seven variables in Table 7 and demonstrated that as compli-
ance increased, SSI rates came down.
83
An important remain-
ing issue is the proper duration of prophylaxis in complicated
cases, in the setting of trauma, and in the presence of foreign
bodies. No change in the criteria for antibiotic prophylaxis is
required in laparoscopic procedures; the risk of infection is
lower in such cases.
84,85
Cost factors are important and may
justify the endless succession of studies that compare new
drugs in competition for appropriate clinical niches.
Further advances in patient selection may take place but
will require analysis of data from large numbers of patients
and a distinction between approaches to infection of the
wound, which is only part of the operative eld, and
approaches to infections directly related to the operative site.
These developments will dene more clearly the prophylaxis
requirements of patients whose operations are clean but
whose risk of wound or operative site infection is increased.
A current issue of some concern is loss of infection surveil-
lance capability. Infection control units have been shown to
offer a number of benets in the institutional setting, such as
the following:
1. Identifying epidemics caused by common or uncommon
organisms
24,27,57
2. Establishing correct use of prophylaxis (timing, dose, dura-
tion, and choice)
53,56,74
3. Documenting costs, risk factors, and readmission
rates
86,87
4. Monitoring postdischarge infections and secondary conse-
quences of infections
8890
5. Ensuring patient safety
91
6. Managing MRSA and VRE
92
S. aureusin particular, MRSAis a major cause of SSI.
92
Cross-infection problems are a concern, in a manner reminis-
cent of the preantibiotic era. Hand washing (see below) is
coming back into fashion, consistent with the professional
behavior toward cross-infection characteristic of the preanti-
biotic era. At present, hard evidence is lacking, but clinical
observation suggests that S. aureus SSIs are especially trou-
blesome and destructive of local tissue and require a longer
time to heal than other SSIs do. When S. aureus SSIs occur
after cardiac surgery, thoracotomy, or joint replacement, their
consequences are signicant. Prevention in these settings is
important. When nasal carriage of S. aureus has been identi-
ed, mupirocin may be administered intranasally to reduce
the incidence of S. aureus SSIs.
93
The benets of infection surveillance notwithstanding, as
the business of hospital care has become more expensive and
nancial control more rigid, the infection control unit is a
hospital component that many administrators have come to
consider a luxury and therefore expendable. Consequently,
surveillance as a quality control and patient safety mechanism
has been diminished.
It is apparent that SSIs have huge clinical and nancial
implications [see Sidebar Patient Safety and Antibiotic Use].
Patients with infections tend to be sicker and to undergo
more complex operations. Therefore, higher infection rates
translate into higher morbidity and mortality as well as higher
cost to the hospital, the patient, and society as a whole. With
increasingly early discharge becoming the norm, delayed
diagnosis of postdischarge SSI and the complications thereof
Table 7 Quality Improvement Objectives to Reduce
Surgical Site Infections
80,83
Timeliness of antibiotics
Appropriate selection of antibiotics
Correct duration of antibiotics
Preventing hyperglycemia
Maintaining normothermia
Optimizing oxygen tension
Avoidance of shaving surgical site
2008 BC Decker Inc ACS Surgery: Principles and Practice
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is a growing problem.
8890
Effective use of institutional
databases may contribute greatly to identication of this
problem.
89
Clearly, the development of effective mechanisms for
identifying and controlling SSIs is in the interests of all
associated with the delivery of health care.
91
The identica-
tion of problems by means of surveillance and feedback
can make a substantial contribution to reducing SSI rates
[see Table 6].
13,91
Patient Safety and Antibiotic Use
Prophylactic antibiotics have been considered to be a harmless
manner in which to prevent surgical site infections. The evidence
is that a single dose of prophylactic antibiotics can precipitate
Clostridium difcile pseudomembraneous enterocolitis.
63
These can
be as malignant as the same entity caused by therapeutic antibiotic
regimens.
Although the principles of delivery of added prophylactic
antibiotics and their duration have been established for a long
time, the evidence is clear that adherence to these principles is
frequently poor. Two areas that are primarily at fault are the timing
of administration of the rst dose and whether it gets given and
the duration of use of prophylactic antibiotics.
43,7072
The principles
are (1) that the drug must be at the site of the wound at the
time of incision and (2) a duration longer than 24 hours has no
positive impact on SSI and may have a negative one. The inability
of hospitals around the world to ensure the short postoperative
duration of prophylaxis is a puzzle but is clear in all studies thus
far performed.
Although prophylactic antibiotics are not the only stimulus to
produce resistant microora, their control and correct management
will contribute to decreasing the incidence of methicillin-
resistant Staphylococcus aureus (MRSA) and vancomycin-resistant
enterococcus (VRE). MRSA, in particular, is now found in
community practice clearly as a result of excessive antibiotic use.
The key to effective prophylactic antibiotics use and decreased
pressure for antibiotic resistance can be simplied to the right drug,
the right timing, and the right duration The increased use of third-
and fourth-generation antibiotics is to be strongly discouraged.
The new recommendations for the use of antibiotics in the
prevention of infective endocarditis in association with either dental
or other operative procedures are clear. The number of conditions
has been reduced and claried, and the recommendations regarding
procedures have been greatly simplied.
118,119
All recommendations for prophylactic antibiotics, whatever
the indication, suggest the use of rst- or second-generation
cephalosporins, ampicillin or its derivatives, metronidazole, and
rst-generation erythromycins and aminoglycosides.
56,118
naNu wasniNc
The purpose of cleansing the surgeons hands is to reduce
the numbers of resident ora and transient contaminants,
thereby decreasing the risk of transmitting infection. Although
the proper duration of the hand scrub is still subject to debate,
evidence suggests that a 120-second scrub is sufcient,
provided that a brush is used to remove the bacteria residing
in the skin folds around the nails.
94
The nail folds, the nails,
and the ngertips should receive the most attention because
most bacteria are located around the nail folds and most
glove punctures occur at the ngertips. Friction is required
to remove resident microorganisms that are attached by
adhesion or adsorption, whereas transient bacteria are easily
removed by simple hand washing.
Solutions containing either chlorhexidine gluconate or
one of the iodophors are the most effective surgical scrub
preparations and have the fewest problems with stability,
contamination, and toxicity.
95
Alcohols applied to the skin
are among the safest known antiseptics, and they produce
the greatest and most rapid reduction in bacterial counts on
clean skin.
96
All variables considered, chlorhexidine gluconate
followed by an iodophor appears to be the best option [see
Table 8].
The purpose of washing the hands after surgery is to
remove microorganisms that are resident, that ourished in
the warm, wet environment created by wearing gloves, or that
reached the hands by entering through puncture holes in the
gloves. On the ward, even minimal contact with colonized
patients has been demonstrated to transfer microorganisms.
97
As many as 1,000 organisms were transferred by simply
touching the patients hand, taking a pulse, or lifting the
patient. The organisms survived for 20 to 150 minutes,
making their transfer to the next patient clearly possible.
A return to the ancient practice of washing hands between
each patient contact is warranted. Nosocomial spread of
numerous organismsincluding C. difcile; MRSA, VRE,
and other antibiotic-resistant bacteria; and virusesis a
constant threat.
Hand washing on the ward is complicated by the fact that
overwashing may actually increase bacterial counts. Dry,
damaged skin harbors many more bacteria than healthy skin
and is almost impossible to render even close to bacteria free.
Although little is known about the physiologic changes in
skin that result from frequent washings, the bacterial ora is
certainly modied by alterations in the lipid or water content
of the skin. The so-called dry hand syndrome was the impe-
tus behind the development of the alcohol-based gels now
available. These preparations make it easy for surgeons to
Table 8 Characteristics of Three Topical Antimicrobial Agents Effective against Both Gram-Positive and Gram-Negative
Bacteria
96
Agent Mode of Action Antifungal Activity Comments
Chlorhexidine Cell wall disruption Fair Poor activity against tuberculosis-causing organisms; can
cause ototoxicity and eye irritation
Iodine/iodophors Oxidation and substitution by
free iodine
Good Broad antibacterial spectrum; minimal skin residual
activity; possible absorption toxicity and skin irritation
Alcohols Denaturation of protein Good Rapid action but little residual activity; ammable
2008 BC Decker Inc ACS Surgery: Principles and Practice
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clean their hands after every patient encounter with minimal
damage to their skin.
iNrcc1ioN incvcN1ioN iN nowcL scnccnv
At present, the best method of preventing SSIs after bowel
surgery is, once again, a subject of debate. There have been
three principal approaches to this issue, involving mechanical
bowel preparation in conjunction with one of the following
three antibiotic regimens
56,98103
:
1. Oral antibiotics (usually neomycin and erythromycin),
1621,102
2. Intravenous antibiotics covering aerobic and anaerobic
bowel ora,
1621,56,100,101
or
3. A combination of regimens 1 and 2 (meta-analysis
suggests that the combination of oral and parenteral
antibiotics is best).
103
With respect to mechanical bowel preparation, there are
now many trials that in modern times have failed to be
supportive.
1619
Meta-analysis suggests no value in the preven-
tion of infection and the possibility of increasing complica-
tions.
16,21
The increased SSI and leak rates noted have been
attributed to the complications associated with vigorous
bowel preparation, leading to dehydration, overhydration, or
electrolyte abnormalities.
An observational study reported a 26% SSI rate in colorec-
tal surgery patients.
104
Intraoperative hypotension and body
mass index were the only independent predictive variables.
All patients underwent mechanical bowel preparation the
day before operation and received oral antibiotics and periop-
erative IV antibiotics. Half of the SSIs were discovered after
discharge. Most would agree that the protocol was standard.
These and other results suggest that a fresh look at the
infectious complications of surgeryand of bowel surgery in
particularis required.
iN1ccna1ioN or uc1cn:iNaN1s or iNrcc1ioN
The signicant advances in the control of wound infection
during the past several decades are linked to a better
understanding of the biology of wound infection, and this link
has permitted the advance to the concept of SSI.
2
In all tis-
sues at any time, there will be a critical inoculum of bacteria
that would cause an infectious process [see Figure 3]. The
standard denition of infection in urine and sputum has been
10
5
organisms/mL. In a clean dry wound, 10
5
bacteria pro-
duce a wound infection rate of 50% [see Figure 3].
12
Effective
use of antibiotics reduces the infection rate to 10% with the
same number of bacteria and thereby permits the wound to
tolerate a much larger number of bacteria.
All of the clinical activities described are intended either
to reduce the inoculum or to permit the host to manage
the number of bacteria that would otherwise be pathologic.
One study in guinea pigs showed how manipulation of local
blood ow, shock, the local immune response, and foreign
material can enhance the development of infection.
105
This
study and two others dened an early decisive period of
host antimicrobial activity that lasts for 3 to 6 hours after
contamination.
51,105,106
Bacteria that remain after this period
are the infecting inoculum. Processes that interfere with this
early response (e.g., shock, altered perfusion, adjuvants, or
foreign material) or support it (e.g., antibiotics or total care)
have a major inuence on outcome.
One investigation demonstrated that silk sutures decrease
the number of bacteria required for infection.
107
Other inves-
tigators used a suture as the key adjuvant in studies of host
manipulation,
108
whereas a separate study demonstrated
persistent susceptibility to wound infection days after shock.
109
The common variable is the number of bacteria. This relation
may be termed the inoculum effect, and it has great relevance
in all aspects of infection control. Applying knowledge of this
effect in practical terms involves the following three steps:
1. Keeping the bacterial contamination as low as possible via
asepsis and antisepsis, preoperative preparation of patient
and surgeon, and antibiotic prophylaxis
2. Maintaining local factors in such a way that they can pre-
vent the lodgment of bacteria and thereby provide a locally
unreceptive environment
3. Maintaining systemic responses at such a level that they
can control the bacteria that become established
These three steps are related to the determinants of infec-
tion and their applicability to daily practice. Year-by-year
reductions in wound infection rates, when closely followed,
indicate that it is possible for surgeons to continue improving
results by attention to quality of clinical care and surgical
technique, despite increasingly complex operations.
5,14,2931
In
particular, the measures involved in the rst step (control of
bacteria) have been progressively rened and are now well
established.
The integration of determinants has signicant effects [see
Figures 3 and 4]. When wound closure was effected with a
wound hematocrit of 8% or more, the inoculum required
to produce a wound infection rate of 40% was 100 bacteria
[see Figure 3]. Ten bacteria produced a wound infection rate
of 20%. The shift in the number of organisms required to
produce clinical infection is signicant. It is obvious that this
inoculum effect can be changed dramatically by good surgical
technique and further altered by use of prophylactic antibiot-
ics. If the inoculum is always slightly smaller than the number
of organisms required to produce infection in any given
setting, the results are excellent. There is clearly a relation
between the number of bacteria and the local environment.
The local effect can also be seen secondary to systemic phy-
siologic change, specically shock. One study showed the low
local perfusion in shock to be important in the development
of an infection.
105,106
One investigation has shown that shock can alter infection
rates immediately after its occurrence [see Figure 4].
109
Fur-
thermore, if the inoculum is large enough, antibiotics will
not control bacteria. In addition, there is a late augmentation
of infection lasting up to 3 days after restoration of blood
volume. These early and late effects indicate that systemic
determinants come into play after local effects are resolved.
These observations call for further study, but, obviously, the
combined abnormalities alter the outcome.
Systemic host responses are important for the control of
infection. The patient has been clearly implicated as one
of the four critical variables in the development of wound
infection.
6
In addition, the bacterial inoculum, the location
of the procedure and its duration, and the coexistence of
three or more diagnoses were found to give a more accurate
prediction of the risk of wound infection. The spread of risk
is dened better with the SENIC index (1 to 27%) than it
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
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is with the traditional classication (2.9 to 12.6%). The
importance of the number of bacteria is lessened if the other
factors are considered in addition to inoculum. The inoculum
effect has to be considered with respect to both the number
of organisms and the local and systemic host factors that are
in play. Certain variables were found to be signicantly
related to the risk of wound infection in three important
prospective studies.
6,11,13
It is apparent that the problem of
SSI cannot be examined only with respect to the manage-
ment of bacteria. Host factors have become much more sig-
nicant now that the bacterial inoculum can be maintained
at low levels by means of asepsis, antisepsis, technique, and
prophylactic antibiotics.
110
Important host variables include the maintenance of
normal homeostasis (physiology) and immune response.
Maintenance of normal homeostasis in patients at risk is one
of the great advances of surgical critical care.
110
The clearest
improvements in this regard have come in maintenance of
blood volume, oxygenation, and oxygen delivery.
One group demonstrated the importance of oxygen
delivery, tissue perfusion, and P
a
O
2
in the development of
wound infection.
111
Oxygen can have as powerful a negative
inuence on the development of SSI as antibiotics can.
112
The
inuence is very similar to that seen in other investigations.
Whereas a P
a
O
2
equivalent to a true fractional concentration
of oxygen in inspired gas (F
I
O
2
) of 45% is not feasible,
maintenance, when appropriate, of an increased F
I
O
2
in the
postoperative period may prove an elementary and effective
tool in managing the inoculum effect.
Modern surgical practice has reduced the rate of wound
infection signicantly. Consequently, it is more useful to
think in terms of SSI, which is not limited to the incision
but may occur anywhere in the operative eld; this concept
provides a global objective for control of infections associated
with a surgical procedure. Surveillance is of great importance
for quality assurance. Reports of recognized pathogens (e.g.,
S. epidermidis and group A streptococci) and unusual organ-
isms (e.g., Rhodococcus [Gordona] bronchialis, Mycoplasma
hominis, and Legionella dumofi) in SSIs highlight the impor-
tance of infection control and epidemiology for quality assur-
ance in surgical departments.
2224,27,28
(Although these reports
use the term wound infection, they are addressing what we now
call SSI.) The importance of surgeon-specic and service-
specic SSI reports should be clear [see Table 6]
13,14,113
and
their value in quality assurance evident.
References
1. Meakins JL. Host defence mechanisms:
evaluation and roles of acquired defects and
immunotherapy. Can J Surg 1975;18:259.
2. 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.
3. Horan TC, Gaynes RP, Martone WJ, et al.
CDC denitions of nosocomial surgical site
infections, 1992: a modication of CDC
denitions of surgical wound infections.
Infect Control Hosp Epidemiol 1992;13:
606.
4. Wilson APR, Gibbons C, Reeves BC, et al.
Surgical wound infection as a performance
indicator: agreement of common denitions
of wound infection in 4773 patients. BMJ
2004;329:720.
5. Report of an Ad Hoc Committee of the
Committee on Trauma, Division of Medical
Sciences, National Academy of Sciences-
National Research Council. Postoperative
wound infections: the inuence of ultraviolet
irradiation of the operating room and of
various other factors. Ann Surg 1964;
Suppl 1:160.
6. Haley RW, Culver DH, Morgan WM, et al.
Identifying patients at high risk of surgical
wound infection: a simple multivariate index
of patient susceptibility and wound
contamination. Am J Epidemiol 1985;121:
206.
7. Mangram AJ, Horan TC, Pearson ML, et
al. The Hospital Infection Control Practices
Advisory Committee: guideline for
prevention of surgical site infection, 1999.
Infect Control Hosp Epidemiol 1999;20:
247.
8. Culver DH, Horan TC, Gaynes RP, et al.
Surgical wound infection rates by wound
class, operative procedure and patient risk
index. Am J Med 1991;91(Suppl 3B):153S.
9. Farias-lvarez C, Farias C, Prieto D, et al.
Applicability of two surgical-site infection
risk indices to risk of sepsis in surgical
patients. Infect Control Hosp Epidemiol
2000;21:633.
10. Neumayer L, Hosokawa P, Itani K, et al.
Multivariable predictors of postoperative
surgical site infection after general and
vascular surgery: results from the Patient
Safety in Surgery Study. J Am Coll Surg
2007;204:1178.
11. Davidson AIG, Clark C, Smith G.
Postoperative wound infection: a computer
analysis. Br J Surg 1971;58:333.
12. Polk HC Jr, Lopez-Mayor JF. Postoperative
wound infection: a prospective study of
determinant factors and prevention. Surgery
1969;66:97.
13. Cruse PJE, Foord R. The epidemiology of
wound infection: a 10-year prospective
study of 62,939 wounds. Surg Clin North
Am 1980;60:27.
14. Olson M, OConnor M, Schwartz ML.
Surgical wound infections: a 5-year
prospective study of 20,193 wounds at the
Minneapolis VA Medical Center. Ann Surg
1984;199:253.
15. Tanner J, Woodings D, Moncaster K.
Preoperative hair removal to reduce surgical
site infection. Cochrane Database Syst Rev
(3): CD004122, 2006.
16. Ram E, Sherman Y, Weil R, et al. Is
mechanical bowel preparation mandatory
for elective colon surgery? A prospective
randomized study. Arch Surg
2005;140:285.
17. Bretagnol F, Alves A, Ricci A, et al. Rectal
cancer surgery without mechanical bowel
preparation. Br J Surg 2007;94:1266.
18. Jung B, Pahlman L, Nystrom PO, et al.
Multicentre randomized clinical trial of
mechanical bowel prepartion in elective
colonic resection. Br J Surg 2007;94:689.
19. Contant CME, Hop WCJ, vant Sant HP, et
al. Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database Syst
Rev (1):CD001544, 2005.
20. Guenaga KF, Matos D, Castro AA, et al.
Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database Syst
Rev 2005 Jan 25;(1):CD001544.
21. Slim K, Vicaut E, Pais Y, et al. Meta-
analysis of randomized clinical trials of
colorectal surgery with or without mechani-
cal bowel preparations. Br J Surg 2004;91:
1125.
22. Boyce JM, Potter-Bynoe G, Opal SM, et al.
A common-source outbreak of Staphylococ-
cus epidermidis infections among patients
undergoing cardiac surgery. J Infect Dis
1990;161:493.
23. Mastro TD, Farley TA, Elliott JA, et al. An
outbreak of surgical-wound infections due
to group A streptococcus carried on the
scalp. N Engl J Med 1990;323:968.
24. Richet HM, Craven PC, Brown JM, et al. A
cluster of Rhodococcus (Gordona)
bronchialis sternal-wound infections after
coronary-artery bypass surgery. N Engl J
Med 1991;324:104.
25. Moylan JA, Kennedy BV. The importance
of gown and drape barriers in the prevention
of wound infection. Surg Gynecol Obstet
1980;151:465.
26. Garibaldi RA, Maglio S, Lerer T, et al.
Comparison of nonwoven and woven gown
and drape fabric to prevent intraoperative
wound contamination and postoperative
infection. Am J Surg 1986;152:505.
27. Lowry PW, Blankenship RJ, Gridley W, et
al. A cluster of Legionella sternal-wound
infections due to postoperative topical
exposure to contaminated tap water. N Engl
J Med 1991;324:109.
28. Wilson ME, Dietze C. Mycoplasma hominis
surgical wound infection: a case report and
discussion. Surgery 1988;103:257.
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
INFECTION 19
06/08
29. Cruse PJE. Surgical wound sepsis. Can Med
Assoc J 1970;102:251.
30. Wangensteen OH, Wangensteen SD. The
rise of surgery: emergence from empiric
craft to scientic discipline. Minneapolis:
University of Minnesota Press; 1978.
31. Cruse PJE. Wound infections: epidemiology
and clinical characteristics. In: Howard RJ,
Simmons RL, editors. Surgical infectious
disease. 2nd ed. Norwalk, CT: Appleton
and Lange; 1988. p. 319330.
32. Petrowsky H, Demartines N, Rousson V, et
al. Evidence-based value of prophylactic
drainage in gastrointestinal surgery: a
systematic review and meta-analyses. Ann
Surg 2004;240:1074.
33. Hopf HW, Hunt TK, West JM, et al.
Wound tissue oxygen tension predicts the
risk of wound infection in surgical patients.
Arch Surg 1997;132:997.
34. Greif R, Akca O, Horn EP, et al.
Supplemental perioperative oxygen to
reduce the incidence of surgical-wound
infection. Outcomes Research Group. N
Engl J Med 2000;342:161.
35. Pryor KO, Fahey TJ, Lien CY, et al. Surgical
site infection and the routine use of
perioperative hyperoxia in a general surgical
population: a randomized controlled trial.
JAMA 2004;291:79.
36. Gottrup F. Prevention of surgical-wound
infections. N Engl J Med 2000;342:202.
37. Kaye KS, Schmit K, Pieper C, et al. The
effect of increasing age on the risk of surgical
site infection. J Infect Dis 2005;191:1056.
38. 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;22:607.
39. Furnary AP, Zerr KJ, Grunkemeier GI, et
al. 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.
40. Van Den Berghe G, Wouters P, Weekers F,
et al. Intensive insulin therapy in critically ill
patients. N Engl J Med 2001;345:1359.
41. Kurz H, Sessler DI, Lenhardt R.
Perioperative normothermia to reduce the
incidence of surgical wound infection and
shorten hospitalization. N Engl J Med
1996;334:1209.
42. Nichols RL, Smith JW, Klein DB, et al. Risk
of infection after penetrating abdominal
trauma. N Engl J Med 1984;311:1065.
43. Jensen LS, Andersen A, Fristup SC, et al.
Comparison of one dose versus three doses
of prophylactic antibiotics, and the inuence
of blood transfusion, on infectious
complications in acute and elective colorectal
surgery. Br J Surg 1990;77:513.
44. Mller AM, Villebro N, Pedersen T, et al.
Effect of preoperative smoking intervention
on postoperative complications: a rando-
mised clinical trial. Lancet 2002;359:114.
45. Buggy D. Can anaesthetic management
inuence surgical wound healing? Lancet
2000;356:355.
46. Melling AC, Ali B, Scott EM, et al. Effects
of preoperative warming on the incidence
of wound infection after clean surgery: a
randomised controlled trial. Lancet 2001;
358:876.
47. Horn SD, Wright HL, Couperus JJ, et al.
Association between patient-controlled
analgesia pump use and postoperative
surgical site infection in intestinal surgery
patients. Surg Infect 2002;3:109.
48. Bennett SN, McNeil MM, Bland LA, et al.
Post-operative infections traced to
contamination of an intravenous anesthetic:
propofol. N Engl J Med 1995;333:147.
49. Nichols RL, Smith JW. Bacterial
contamination of an anesthetic agent. N
Engl J Med 1995;333:184.
50. Miles AA, Miles EM, Burke J. The value
and duration of defense reactions of the skin
to the primary lodgment of bacteria. Br J
Exp Pathol 1957;38:79.
51. Burke JF. The effective period of preventive
antibiotic action in experimental incisions
and dermal lesions. Surgery 1961;50:161.
52. Bernard HR, Cole WR. The prophylaxis of
surgical infection: the effect of prophylactic
antimicrobial drugs on incidence of infection
following potentially contaminated wounds.
Surgery 1964;56:151.
53. Classen DC, Evans RS, Pestotnik SC, et al.
The timing of prophylactic administration
of antibiotics and the risk of surgical-wound
infection. N Engl J Med 1992;326:282.
54. Scottish Intercollegiate Guidelines Network.
Antibiotic prophylaxis in surgery. Available
at: http://www.show.scot.nhs.uk/sign/guide-
lines/fulltext/45/section1.html (accessed
December 11, 2004).
55. Burke JP. Maximizing appropriate antibiotic
prophylaxis for surgical patients: an update
from LDS Hospital, Salt Lake City. Clin
Infect Dis 2001;33(Suppl):78.
56. Antimicrobial prophylaxis for surgery:
treatment guidelines. Med Lett 2006;4:83.
57. Kaiser AB. Surgical wound infection. N
Engl J Med 1991;324:123.
58. Finland M. Antibacterial agents: uses and
abuses in treatment and prophylaxis. RI
Med J 1960;43:499.
59. Platt R, Zaleznik DF, Hopkins CC, et al.
Perioperative antibiotic prophylaxis for
herniorrhaphy and breast surgery. N Engl J
Med 1990;322:153.
60. Taylor EW, Duffy K, Lee K, et al. Surgical
site infection after groin hernia repair. Br J
Surg 2004;91:105.
61. Aufenacker TJ, van Geldere D, Bossers AN,
et al. The role of antibiotic prophylaxis
in prevention of wound infection after
Lichtenstein open mesh repair of primary
inguinal hernia: a multicenter double-blind
randomized controlled trial. Ann Surg
2005;240:955.
62. Perez AR, Roxas MF, Hilvano SS. A
randomized, double-blind placebo-
controlled trial to deter effectiveness of
antibiotic prophylaxis for tension-free mesh
herniorrhaphy. J Am Coll Surg 2005;
200:393.
63. Yee J, Dixon CM, McLean APH, et al.
Clostridium difcile disease in a department
of surgery: the signicance of prophylactic
antibiotics. Arch Surg 1991;126:241.
64. Meijer WS, Schmitz PI, Jeekel J. Meta-
analysis of randomized, controlled clinical
trials of antibiotic prophylaxis in biliary tract
surgery. Br J Surg 1990;77:283.
65. Rotman N, Hay J-M, Lacaine F, et al.
Prophylactic antibiotherapy in abdominal
surgery: rst- vs third-generation cephalo-
sporins. Arch Surg 1989;124:323.
66. Washington JA III, Dearing WH, Judd ES,
et al. Effect of preoperative antibiotic
regimen on development of infection after
intestinal surgery. Ann Surg 1974;180:567.
67. Fullen WD, Hunt J, Altemeier WA.
Prophylactic antibiotics in penetrating
wounds of the abdomen. J Trauma 1972;
12:282.
68. Gentry LO, Feliciano DV, Lea AS, et al.
Perioperative antibiotic therapy for
penetrating injuries of the abdomen. Ann
Surg 1984;200:561.
69. Heseltine PNR, Yellin AE, Appleman MD,
et al. Perforated and gangrenous appen-
dicitis: an analysis of antibiotic failures.
J Infect Dis 1983;148:322.
70. Bratzler DW, Houck PM, Richards C, et al.
Use of antimicrobial prophylaxis for major
surgery. Arch Surg 2005;140:174.
71. Girotti MJ, Fodoruk S, Irvine-Meek J, et al.
Antibiotic handbook and pre-printed
perioperative order forms for surgical
prophylaxis: do they work? Can J Surg
1990;33:385.
72. Larsen RA, Evans RS, Burke JP, et al.
Improved perioperative antibiotic use and
reduced surgical wound infections through
use of computer decision analysis. Infect
Control Hosp Epidemiol 1989;10:316.
73. Manian FA, Meyer PL, Setzer J, et al.
Surgical site infections associated with
methicillin-resistant Staphylococcus aureus:
do postoperative factors play a role? Clin
Infect Dis 2003;36:863.
74. Stone HN, Haney BB, Kolb LD, et al.
Prophylactic and preventive antibiotic
therapy: timing duration and economics.
Ann Surg 1978;189:691.
75. Fabian TC, Croce MA, Payne LW, et al.
Duration of antibiotic therapy for penetrating
abdominal trauma: a prospective trial.
Surgery 1992;112:788.
76. Sarmiento JM, Aristizabal G, Rubiano J, et
al. Prophylactic antibiotics in abdominal
trauma. J Trauma 1994;37:803.
77. Hofstetter SR, Pachter HL, Bailey AA, et al.
A prospective comparison of two regimens
of prophylactic antibiotics in abdominal
trauma: cefoxitin versus triple drug. J
Trauma 1984;24:307.
78. Dellinger EP. Antibiotic prophylaxis in
trauma: penetrating abdominal injuries and
open fractures. Rev Infect Dis 1991;13:
5847.
79. Boxma H, Broekhuisen T, Patka P, et al.
Randomized controlled trial of single-dose
antibiotic prophylaxis in surgical treatment
of closed fractures: the Dutch Trauma Trial.
Lancet 1996;347:1133.
80. Surgical Care Improvement Project (SCIP)
Module 1: infection prevention update.
Available at: http://medqic.org/dcs/Content
Server?cid=1101332573904&pagename=
Medqic%2FMQLiterature%2FLiterature
Template&c=MQLiterature. (accessed
January 22, 2008).
81. Fry DE. The Surgical Infection Prevention
(SIP) project: processes, outcomes, and
future impact. Surg Infect 2006;7:S-17.
82. Hedrick TL, Turrentine, FE, Smith RL, et
al. Single-institutional experience with the
Surgical Infection Prevention (SIP) project
in intra-abdominal surgery. Surg Infect
2007;8:425.
83. Dellinger EP, Hausmann SM, Bratzler DW,
et al. Hospitals collaborate to decrease
surgical site infections. Am J Surg 2005;
190:9.
84. Illig KA, Schmidt E, Cavanaugh J, et al. Are
prophylactic antibiotics required for elective
2008 BC Decker Inc ACS Surgery: Principles and Practice
1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 1 PREVENTION OF POSTOPERATIVE
INFECTION 20
06/08
laparoscopic cholecystectomy? J Am Coll
Surg 1997;184:353.
85. Richards C, Edwards J, Culver D, et al.
Does using a laparoscopic approach to
cholecystectomy decrease the risk of surgical
site infection? Ann Surg 2003;237:358.
86. Kirkland KB, Briggs JP, Trivette SL, et al.
The impact of surgical-site infection in
1990s: attributable mortality, excess length
of hospitalisation, and extra costs. Infect
Control Hosp Epidemiol 1999;20:725.
87. Gaynes RP. Surveillance of surgical-site
infections: the world coming together?
Infect Control Hosp Epidemiol 2000;21:
309.
88. Weiss CA, Statz CL, Dahms RA, et al. Six
years of surgical wound infection surveillance
at a tertiary care center. Arch Surg
1999;134:1041.
89. Sands K, Vineyard G, Livingston J, et al.
Efcient identication of postdischarge
surgical site infections: use of automated
pharmacy dispensing information, admini-
strative data, and medical record infor-
mation. J Infect Dis 1 1999;79:434.
90. Platt R. Progress in surgical-site infection
surveillance. Infect Control Hosp Epidemiol
2002;23:361.
91. Burke JP. Infection controla problem for
patient safety. N Engl J Med 2003;348:651.
92. Simor AE, Ofner-Agostini M, Bryce E, et al.
The evolution of methicillin-resistant
Staphylococcus aureus in Canadian hos-
pitals: 5 years of national surveillance.
CMAJ 2001;165:21.
93. Perl TM, Cullen JJ, Wenzel RP, et al.
Intranasal mupirocin to prevent post-
operative Staphylococcus aureus infections.
N Engl J Med 2002;346:1871.
94. Lowbury EJL, Lilly HA, Bull JP. Methods
for disinfection of hands and operation sites.
Br Med J 1964;2:531.
95. Aly R, Maibach HI. Comparative
antibacterial efcacy of a 2-minute surgical
scrub with chlorhexidine gluconate,
povidone-iodine, and chloroxylenol sponge-
brushes. Am J Infect Control 1988;16:173.
96. Larson E. Guideline for use of topical
antimicrobial agents. Am J Infect Control
1988;16:253.
97. Casewell M, Phillips I. Hands as route of
transmission for Klebsiella species. Br Med
J 1977;2:1315.
98. Jagelman DG, Fabian TC, Nichols RL,
et al. Single dose cefotetan versus multiple
dose cefoxitin as prophylaxis in colorectal
surgery. Am J Surg 1988;155(Suppl 5A):
71.
99. Periti P, Mazzei T, Tonelli F, et al. Single
dose cefotetan versus multiple dose
cefoxitinantimicrobial prophylaxis in
colorectal surgery. Dis Colon Rectum
1989;32:121.
100. Norwegian Study Group for Colorectal
Surgery Should antimicrobial prophylaxis in
colorectal surgery include agents effective
against both anaerobic and aerobic micro-
organisms? A double-blind, multicenter
study. Surgery 1985;97:402.
101. Song J, Glenny AM. Antimicrobial
prophylaxis in colorectal surgery: a
systematic review of randomized controlled
trials. Br J Surg 1998;85:1232.
102. Condon RE, Bartlett JG, Greenlee H, et al.
Efcacy of oral and systemic antibiotic
prophylaxis in colo-rectal operations. Arch
Surg 1983;118:496.
103. Lewis RT. Oral versus systemic antibiotic
prophylaxis in elective colon surgery: a
randomized study and meta-analysis send a
message from the 1990s. Can J Surg
2002;45:173.
104. Smith RL, Bohl JK, McElearney ST, et al.
Wound infection after elective colorectal
resection. Ann Surg 2004;239:599.
105. Miles AA, Miles EM, Burke J. The value
and duration of defence reactions of the skin
to the primary lodgement of bacteria. Br J
Exp Pathol 1957;38:79.
106. Miles AA. The inammatory response in
relation to local infections. Surg Clin North
Am 1980;60:93.
107. Alexander JW, Alexander WA. Penicillin
prophylaxis of experimental staphylococcal
wound infections. Surg Gynecol Obstet
1965;120:243.
108. Polk HC Jr. The enhancement of host
defenses against infection: search for the
holy grail. Surgery 1986;99:1.
109. Livingston DH, Malangoni MA. An
experimental study of susceptibility to
infection after hemorrhagic shock. Surg
Gynecol Obstet 1989;168:138.
110. Meakins JL. Surgeons, surgery and
immunomodulation. Arch Surg 1991;
126:494.
111. Knighton D, Halliday B, Hunt TK. Oxygen
as an antibiotic: a comparison of the effects
of inspired oxygen concentration and
antibiotic administration on in vivo bacterial
clearance. Arch Surg 1986;121:191.
112. Rabkin J, Hunt TK. Infection and oxygen.
In: Davis JC, Hunt TK, editors. Problem
wounds: the role of oxygen. New York:
Elsevier; 1987. p. 1.
113. Olson MM, Lee JT Jr. Continuous, 10-year
wound infection surveillance: results,
advantages, and unanswered questions.
Arch Surg 1990;125:794.
114. Oreskovich MR, Dellinger EP, Lennard ES,
et al. Duration of preventive antibiotic
administration for penetrating abdominal
trauma. Arch Surg 1982;117:200.
115. Langely JM, Le Blanc JC, Drake J, et al.
Efcacy of antimicrobial prophylaxis in
placement of cerebrospinal uid shunts:
meta-analysis. Clin Infect Dis 1993;17:98.
116. Tejirian T, DiFronzo LA, Haigh PI.
Antibiotic prophylaxis for preventing wound
infection after breast surgery: a systematic
review and metaanalysis. J Am Coll Surg
2006;203:729.
117. Forse RA, Karam B, MacLean LD, et al.
Antibiotic prophylaxis for surgery in
morbidly obese patients. Surgery 1989;106:
750.
118. Wilson W. Taubert KA, Gewitz M, et al.
Prevention of infective endocarditis: guide-
lines from the American Heart Association.
Circulation 2007;116:1736.
119. Major changes in endocarditis prophylaxis
for dental, GI and GU procedures. Med
Lett Drug Ther 2007;49:99.
120. Hayek LJ, Emerson JM, Gardner AMN.
A placebo-controlled trial of the effect of
two preoperative baths or showers with
chlorhexidine detergent on postoperative
wound infection rates. J Hosp Infect
1987;10:165.
121. Hamilton HW, Hamilton KR, Lone FJ.
Preoperative hair removal. Can J Surg 1977;
20:269.
122. McDonald WS, Nichter LS. Debridement
of bacterial and particulate-contaminated
wounds. Ann Plast Surg 1994;33:142.
123. Edwards PS, Lipp A, Holmes A. Preoperative
skin antiseptics for preventing surgical
wound infections after clean surgery.
Cochrane Database Syst Rev (3):
CD003949, 2004.
Acknowledgment
Figures 3 and 4 Albert Miller.
The author would like to thank Byron J. Master-
son, MD, FACS for his contribution to a previous
iteration of this chapter, on which the current
version is partially based.