Preventing postoperative infection: the
anaesthetist’s role
C Gifford BA (Oxon) BMBCh
N Christelis MBBCH FRCA FFPMRCA FANZCA
A Cheng MBBS FRACP MPH PhD
Key points
Surgical site infection is common
(5–20%) and may be associated
with significant morbidity and even
mortality.
Crucial immune mechanisms such
as neutrophil phagocytosis of
bacteria may be impaired during the
perioperative period.
Multiple randomized controlled
trials and systematic reviews have
consistently shown antibiotic
prophylaxis to be effective in
preventing infections after many
types of surgery.
For effective prophylaxis,
appropriate antibiotics should be
given before skin incision as
recommended by the recent WHO
Safe Surgery Saves Lives surgical
safety checklist.
Potentially modifiable perioperative
factors under control of the
anaesthetist can influence the
incidence of surgical site infection.
C Gifford BA (Oxon) BMBCh
Clinical Fellow, Department of
Anaesthesia and Perioperative Medicine
The Alfred Hospital, Commercial Road
Melbourne, VIC 3004, Australia
N Christelis MBBCH FRCA FFPMRCA
FANZCA
Consultant in Anaesthesia and Pain
Medicine, Headã Acute Pain Service
Department of Anaesthesia and
Perioperative Medicine and Adjunct
Lecturer Monash University, The Alfred
Hospital, Commercial Road, Melbourne,
VIC 3004, Australia
Tel: þ61 3 9076 3176
Fax: þ61 3 9076 2813
E-mail: n.christelis@alfred.org.au
(for correspondence)
A Cheng MBBS FRACP MPH PhD
Associate Professor in Infectious,
Diseases Epidemiology, Department of
Epidemiology and Preventive Medicine
Monash University Infectious Diseases
Physician, The Alfred Hospital, Australia
151
Postoperative surgical patients are at risk of
developing multiple types of hospital-acquired
infections. These include surgical site infec-
tions which are relatively common (incidence
5– 20%), can prolong hospital stay, cause mor-
bidity, increase the cost of health care, and
even lead to mortality. Other hospital-acquired
infections affecting surgical patients include
respiratory and urinary tract infections,
methicillin-resistant Staphylococcus aureus
bacteraemias, antibiotic-related Clostridium
difficile enteritis, and intravascular cannulae-
related infections.
All surgical wounds are likely to become
contaminated, usually by resident bacterial
flora from skin or viscera. This may not be of
clinical significance and contaminated wounds
may go unnoticed. However, progression from
wound contamination to clinical infection is
largely determined by the adequacy of host
defence, the most important immune mechan-
ism of which is neutrophil phagocytosis which
occurs during a crucial few hours intraopera-
tively and after operation. When a neutrophil
ingests bacteria (or any foreign debris), it
undergoes a ‘respiratory burst’, temporarily
increasing its oxygen consumption which
results in the production of anti-microbial
oxygen free radicals. Oxygen free radicals such
as superoxide ions and hydrogen peroxide are
produced by the enzymes superoxide dismutase
and myeloperoxidase. Variables that affect
tissue oxygen delivery or enzyme function can
impair the production of oxygen free radicals
and allow bacteria to survive and infection to
become established.
Well-known variables that influence surgical
site infection include surgical factors (e.g. hae-
matoma, anastomotic leak, poor surgical tech-
nique, choice of antiseptic, prolonged or
technically difficult procedure) and patient
factors (immunosuppression, age, ASA status,
doi:10.1093/bjaceaccp/mkr028
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 11 Number 5 2011
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Matrix reference 1I05
comorbidities, colonization by S. aureus)
(Table 1).
However, there are now a number of emer-
ging factors that can also affect the incidence
of bacterial infections of the surgical site.
Some of these other variables are pre-existing
or unmodifiable, whereas several can be altered
by the anaesthetist. These modifiable factors
will be the focus of this discussion.
Factors that can be optimized in the peri-
operative period can be divided into:
(i) Well-established interventions (supported
by good evidence)
(a) antibiotic prophylaxis,
(b) hand hygiene,
(c) aseptic technique during invasive
procedures,
(d) perioperative thermoregulation.
(ii) Less certain interventions (some support-
ing evidence)
(a) face masks and theatre traffic,
(b) regional anaesthesia techniques,
(c) inspired oxygen,
(d) glycaemic control.
(iii) Speculative interventions (no supportive
evidence as yet)
(a) goal-directed fluid management,
(b) minimizing blood transfusions,
(c) enhanced recovery after surgery
(ERAS),
(d) avoidance of selected opioids.
Antibiotic prophylaxis
Multiple randomized controlled trials and sys-
tematic reviews have consistently shown anti-
biotic prophylaxis to be of benefit in preventing
infections after many types of surgery (Table 2).
The UK National Institute of Clinical
Excellence (NICE) issued guidelines in 2008
Advance Access publication 22 July, 2011
Preventing postoperative infection

recommending a single dose of prophylactic antibiotics i.v. on ‘Clean’ surgery involves no break in aseptic technique and the res-
starting anaesthesia (i.e. before skin incision), or earlier if a tourni- piratory, gastrointestinal, or genitourinary tracts not being breached.
quet is to be used.1 NICE recommends antibiotic prophylaxis for ‘Clean-contaminated’ surgery involves the oropharynx, sterile
the following types of surgery: genitourinary or biliary tract, the gastrointestinal or respiratory
tracts, or where there has been a minor breach in aseptic
† clean surgery involving the placement of a prosthesis or technique.
implant, ‘Contaminated’ surgery is defined as the presence of acute
† clean-contaminated surgery, inflammation, infected bilious secretions, infected urine, or gross
† contaminated surgery. contamination from the gastrointestinal tract.
‘Dirty’ surgery is where an established infection exists and
Table 1 Risk factors for development of postoperative surgical infection. *Factors therapeutic antibiotics are administered based on the susceptibility
modifiable by the anaesthetist of bacterial isolates grown from culture.
Patient factors Perioperative variables Prophylactic antibiotic administration reduces the bacterial
inoculum at the time of surgery and significantly decreases the rate
Diabetes mellitus Operating theatre characteristics
Obesity Use of foreign materials
of bacterial contamination of the surgical site. For effective pro-
Smoking Antibiotic prophylaxis* phylaxis, evidence has shown that the minimum inhibitory concen-
Bacterial colonization Hand hygeine* tration of the antibiotic agent at tissue level must be exceeded for,
Remote infection Invasive anaesthetic procedures*
Older age Hypothermia*
at least, the period from incision to wound closure.2 Hence the
Underlying illness Face masks and theatre traffic* timing of the prophylactic antibiotics is crucial. This is an area
Malnutrition Regional anaesthesia* where anaesthetists can have a significant impact on reducing
Hypoxaemia Tissue oxygenation*
Surgical technique Perioperative glycaemic control*
patient risks of infection. Observational studies have shown that
Site and type of surgery Volume status and fluid replacement* the infection rate is lowest if antibiotics are administered within 30
Length of procedure Transfusion of allogeneic blood products* min of incision, with the odds of infection increasing two-fold if
Postoperative pain control*
antibiotics were administered either after incision or .60 min

Table 2 Antibiotic prophylaxis in specific surgical procedures: evidence from Cochrane Library of Systematic Reviews (www.cochrane.org/cochrane-reviews)

Operation Infection risk Pathogens Antibiotics Relative risk if given antibiotic (95% CI)

Appendicectomy Up to 40% Escherichia coli Cephalosporins 0.33 (0.29 – 0.38)

Klebsiella Imidazoles
Proteus
Bacteroides
Breast cancer surgery 3–15% Not specifically mentioned Cephalosporins 0.72 (0.53 – 0.97)
Azithromycin
Augmentin
Caesarean section 20 –80% E. coli, gram negatives, group B Cephalosporins Endometritis 0.38 (0.34 –0.42)
strep, streps, Enterococcus
faecalis, Staphs, anaerobes
Ampicillin (equally effective) Wound infection 0.39 (0.32 –0.48)
Colorectal 40% Aerobes and anaerobes Aerobic and anaerobic, e.g. 0.30 (0.22 – 0.41)
cephalosporin and
metronidazole
Compound fractures 11% Gram-positive organisms Penicillins 0.43 (0.29 – 0.65)
Cephalosporins (1st gen)
Dental implants 6% implant failure Oral flora Ampicillin 0.22 (0.06 – 0.86)
Ear surgery – clean and 5–10% Not specifically mentioned Penicillins No benefit
clean-contaminated
Cephalosporins
Clindamycin/gentamicin
Closed long bone fractures Not given Staphylococci Cephalosporins 0.40 (0.19 – 0.62)
Hernia repair 4% Gram-positive cocci Augmentin Trend towards benefit in mesh use only
Cephalosporins
Tonsillectomy Unclear Oral commensals Penicillins No benefit
0.49 (0.08 – 3.11)
Vascular grafts Not given Skin commensals Cephalosporins 0.25 (0.17 – 0.38)
Staphs and gram negatives Vancomycin
Intracranial ventricular shunt 1.5 –38% Not specifically mentioned Cephalosporins NNT 12
insertion
Vancomycin OR 0.52 (0.36 –0.74)

152 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011

before incision. Timing of antibiotic prophylaxis is so important
that the recent World Health Organization (WHO) initiative, Safe
Surgery Saves Lives surgical safety checklist emphasizes the
inclusion of antibiotic prophylaxis given within 60 min before skin
incision (www.who.int/patientsafety/safesurgery/).
Trusts and hospitals should have locally published guidelines for
surgical antibiotic prophylaxis based on local infective microbes
and their antibiotic resitance patterns. These are usually formulated
by microbiologists in consultation with surgical colleagues and
adhered to in the perioperative setting. For antibiotics with a rela-
tively short half-life, such as cephazolin, a second dose of anti-
biotics is often recommended for prolonged procedures. Prolonged
antibiotic prophylaxis extending after the surgical procedure has not
been shown to be more effective than short-term prophylaxis.
Antibiotics have risks and commonly identified adverse effects
of antibiotic therapy include gastrointestinal symptoms (nausea,
vomiting, or diarrhoea), minor allergic reactions such as skin
rashes myalgias and arthralgias. Rare adverse effects include pan-
cytopenia, kidney or liver dysfunction, and life-threatening anaphy-
laxis. Routine antibiotic prophylaxis is therefore not recommended
for clean, non-prosthetic, uncomplicated surgery.
Hand hygiene
The impact of disinfection of hands on infection rates was first
demonstrated by Semmelweis in the 1840s and the requirement for
the surgical scrub is a well-established principle for surgeons
entering the operating theatre. The advent of disinfection with
alcohol-based hand rub has reduced the time required to perform
hand hygiene before and after every patient contact and is an
accepted method to prevent transmission of resistant organisms
between patients. The World Health Organisation is currently pro-
moting a ‘5 Moments of Hand Hygiene’ strategy as part of a
‘Clean Care Is Safer Care’ programme (http://www.who.int/gpsc/
tools/Five_moments/en/). Trust and hospital appropriate hand
hygiene should be considered and practised with every single
patient contact. This should be done in out-patient clinic settings,
on medical ward rounds, and in the operating department.
Aseptic technique during invasive
anaesthetic procedures
Anaesthetists regularly insert central venous catheters (CVCs) and
epidural catheters which may be portals of entry for bacteria. The
incidence of CVC-related bloodstream infections is reported as
high as 5 –10 per 1000 catheter days.
Guidelines in the UK, USA, and Australia recommend maximal
barrier precautions for the insertion of CVCs, epidural, and nerve
block catheters. This is often considered as part of an ‘insertion
bundle’ approach together with the use of chlorhexidine antisepsis,
careful selection of site, avoidance of unnecessary lines or lumens
(and prompt removal when appropriate), and hand hygiene. One
such bundle, incorporating a systems-based approach to ensure that
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
Preventing postoperative infection
five key behaviours were adhered to, was associated with a signifi-
cant and sustained decrease in CVC-related bloodstream infection
rates in 108 intensive care units.3 They also recommend using 2%
chlorhexidine in alcohol as this has higher efficacy than
povidone-iodine when used for skin antisepsis. However, caution
is still advised when using 2% chlorhexidine in alcohol because of
the significant risk of neurotoxicity if neuronal contamination
occurs, which is a concern when using an epidural technique. The
subclavian site is associated with fewer CVC-related bloodstream
infections when compared with the internal jugular and femoral
sites. There is also some evidence that the use of real-time
ultrasound-guidance during insertion may reduce CVC-related
infections, due to fewer needle insertions and increased speed of
insertion, with reduced incidence of haematoma formation.4 In
high-risk patients, and where other measures have not succeeded
in eliminating CVC-related bloodstream infection, antibiotic-
coated CVCs have been recommended if the CVC is expected to
remain in situ longer than 5 days and is not tunnelled.
Infections involving epidural catheters are reported as rare, but
may be clinically catastrophic. Epidurals should generally be
removed within 72 h or tunnelled as the incidence of infection
increases sharply after this time period. Peripheral nerve catheters
are now increasingly being using as part of a balanced analgesic
approach. Recently, concerns have been raised about peripheral
nerve catheters as a source for prosthetic joint infection after joint
arthroplasty; however, this has not yet been supported by scientific
evidence. Ultrasound-guidance is now commonly used for inser-
tion of peripheral nerve catheters. It may therefore confer the same
benefits as for CVC insertion. In addition, it seems logical to con-
sider inserting nerve block catheters distant from the surgical site
which may further reduce the possibility of infection.
Perioperative thermoregulation
Hypothermia triggers thermoregulatory vasoconstriction, thereby
decreasing subcutaneous tissue oxygen tension. This can signifi-
cantly reduce neutrophil function and collagen deposition in
healing wounds. Hypothermia can also directly impair immune
function. Mild perioperative hypothermia (28C below normal core
body temperature) has been shown to increase wound infection
rates, delay wound healing, increase transfusion requirements, and
lengthen hospital stay.5 It is therefore recommended that patients
undergoing surgical procedures for longer than 45 min have their
core body temperature monitored and are actively warmed if
required, except where specifically required for other surgical
reasons, such as in cardiac surgery.
Face masks and theatre traffic
In most modern hospitals, in order to reduce rates of infections, no
one is permitted to enter the operating theatre suite without
wearing appropriately designated clean theatre clothing. Face
masks, surgical scrubs, and caps form part of this theatre dress
153
Preventing postoperative infection
code established before the development of laminar flow operating
theatres, which are known to reduce the measurable airborne bac-
teria surrounding the patient. The practice of wearing face masks
is believed to minimize the transmission of oropharyngeal and
nasopharyngeal bacteria from operating theatre staff to patients’
wounds, thereby decreasing the likelihood of postoperative surgical
site infections. The evidence for this was reviewed in 20016 and
little was found to support or refute the routine wearing of masks
by surgeons or circulating theatre personnel. In fact, the largest and
best conducted study reviewed showed no statistically significant
difference in infection rates even if the surgical team were
unmasked.7 The reviewers called for further definitive studies,
which have not yet been performed.
Even though evidence suggests a low risk of the patient con-
tracting a respiratory-borne pathogen from unmasked circulating
theatre staff, it is reasonable and considered good medical practice
to continue wearing face masks in the operating suite. Operating
theatre personnel may also choose to wear face masks as a barrier
and means of protection from blood and tissue debris and also
blood- and respiratory-borne infections.
Anaesthetists are often well placed to monitor situations in the
operating theatre environment that may predispose to infection and
thus can act effectively as an advocate for the patient. Such factors
may include the volume of traffic in theatre, the adequacy of
environmental cleaning, and noting breaches in hand hygiene and
aseptic technique.
Regional anaesthesia
Epidural analgesia results in a lower incidence of some postopera-
tive respiratory complications, such as pneumonia, in patients
undergoing laparotomy. This is generally considered to be as a
result of superior analgesia, when compared with systemic opioids,
allowing an increased ability for patients to cough and clear
secretions. In a recent epidemiological study, the use of neuraxial
anaesthesia rather than general anaesthesia has been proposed as
an approach for preventing surgical site infection after lower limb
arthroplasty.8 Proposed mechanisms of reduction in postoperative
surgical infections are via modulation of the inflammatory
response, vasodilation leading to improved tissue oxygenation,
and/or improved postoperative analgesia, particularly with epidural
techniques. Prospective evidence has yet to be collected in
this area.
Inspired gas composition: oxygen vs nitrous
oxide and volatile anaesthetic agents
Increasing the partial pressure of oxygen in the blood and tissues
beyond that which is required to fully saturate haemoglobin has
been postulated to improve the oxidative bactericidal activity of
neutrophils. There is some evidence that giving 80% inspired
oxygen rather than 30% inspired oxygen reduces wound infections
154 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
in colorectal surgery. However, this beneficial effect is not univer-
sal and other studies have failed to reproduce this effect.
In vitro analysis of neutrophil function reveals that a higher
oxygen tension promotes the production of reactive oxygen inter-
mediates required for intracellular cell death and results in an
earlier peak and more rapid decrease in tumour necrosis factor
(TNF-a) levels.
The Enigma Trial revealed that avoidance of inhaled nitrous
oxide intraoperatively reduced the incidence of postoperative infec-
tion among other postoperative complications.9 The ENIGMA-2
trial, currently underway, aims to determine whether this effect
was due to a higher inspired oxygen concentration in the nitrous-
free patient group rather than directly due to the nitrous oxide
itself (www.enigma2.org.au/).
Current guidelines to prevent surgical site infection recommend
only giving the required inspired oxygen concentration to maintain
oxygen saturations above 95%.1
In vitro and animal studies have suggested that volatile
anaesthetic agents may cause a dose-dependent inhibitory effect
on neutrophil function, cytokine release, and lymphocyte prolifer-
ation. Experiments in mice also suggest that volatile agents may
support tumour growth. However, no human data exist to support
this.10
Glycaemic control
Acute hyperglycemia has many deleterious effects. These include
reduced vasodilation, impaired reactive endothelial nitric oxide
generation, decreased complement function, increased expression
of leucocyte and endothelial adhesion molecules, increased con-
centrations of cytokines, and impaired neutrophil chemotaxis and
phagocytosis. These in turn could lead to increased inflammation,
vulnerability to infection, and multiorgan system dysfunction.
Studies have shown that tight glycaemic control [blood glucose
(BG) maintained between 4.5 and 6 mmol dl21] reduces blood-
borne infection rates and hospital mortality, particularly in cardiac
surgical patients. However, concerns remain about the relatively
lax blood sugar control in this clinical trial and studies since have
suggested that tight glycaemic control may be at the expense of an
increase in the number of hypoglycaemic episodes which them-
selves can also be deleterious to physiology and even life threaten-
ing.11 Although it is clear that hyperglycemia is harmful, there is
currently insufficient evidence to support the routine use of tight
glycaemic control (target BG 4.5–6 mmol dl21) in the periopera-
tive period or the intensive care unit setting. It has therefore been
suggested that maintaining BG below 10 mmol dl21 and reducing
BG variability is likely to be both safe and effective.
Fluid management
Traditionally, a liberal approach to fluid infusion during surgery
has been adopted in order to compensate for preoperative fasting,
intraoperative fluid losses, to optimize haemodynamic variables,

and maintain urine output. This can, however, lead to patients
being significantly fluid positive perioperatively which itself can
have detrimental effects. More recently, evidence has begun
to emerge, suggesting that a more restrictive approach to fluid
management reduces complications which include surgical
wound site infections and other forms of sepsis (e.g.
pneumonia-related). ‘Goal-directed’ fluid therapy, requiring inva-
sive monitoring of central venous pressure, pulmonary artery
occlusion pressure, or stroke volume via oesophageal Doppler
probes, has gained some evidence for improved outcomes,
although this does not specifically relate to a reduction in post-
operative infection. These management options should, however,
be considered if available.
Allogeneic blood transfusion
Immunomodulation and immunosuppression are known conse-
quences of allogeneic blood transfusion in humans. A
meta-analysis of observational studies has also shown an associ-
ation between the incidence of postoperative bacterial infection in
transfused patients when compared with matched non-transfused
patients. This effect is greater in trauma patients than surgical
patients in general.12 The effect appears to be dose-related, that is,
the greater the number of blood units and products used, the
greater the risk of infection, but whether this represents residual
confounding is not currently clear. This risk appears to be greater
with older units of red blood cells used, particularly those stored
for .2 weeks. In the trauma or acute surgical setting, blood trans-
fusions may be frequently life saving, and thus it is recommended
that risks and benefits should be considered for each patient before
a blood transfusion is administered. Consideration also needs to be
given to other methods of resuscitation and haemostasis, and also
the use of fresh blood products where possible.
ERAS or fast-track surgery
A relatively new approach to patient management has been
reviewed previously in this journal.13 ERAS utilizes an evidence-
based and structured surgical pathway-based approach to the pre-
operative, perioperative, and postoperative period, emphasizing
patient optimization, education, minimal access surgical tech-
niques, multimodal opioid-sparing analgesic techniques, early
mobilization, early nutrition, and early goal-directed physical
activity. This is aimed at supporting a faster recovery from
surgery, earlier hospital discharge, and ultimately earlier return to
normal function and quality of life.
Many of the objectives targeted by ERAS are also likely to
reduce postoperative surgical infection by reducing the duration of
hospital stay, achieving early mobilization, achieving adequate
analgesia, and minimizing the impact of the postoperative catabolic
state. However, the impact on the incidence of infection rates is yet
to be shown.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 11 Number 5 2011
Preventing postoperative infection
Opioid-induced immunosuppression
The majority of opioids in current clinical practice have the pro-
pensity to suppress the immune system in humans. Morphine, fen-
tanyl, remifentanil, and meperidine, and to a lesser extent
methadone have been shown to possess significant immunosup-
pressive properties. However, oxycodone, buprenorphine, and
hydromorphone have been shown to have no significant effects on
the immune system, and tramadol, due to its complex mechanism
of actions, has been shown to have immuno-enhancing properties.
The most prevalent effects of opioid-induced immunosuppression
have been reported as increased susceptibility to infection,
especially after surgery, trauma, or both, decreased tolerance to
malignant disease with increased likelihood of secondary deposits,
and an increased chance of HIV infection in drug abusers.14
Consequently the patient who is immunocompromised for any
reason such as being on chemotherapeutic agents may be put at
further risk, should an opioid with immunosuppressive activity be
used as part of their treatment. Although variations in postoperative
rates of infection have not been attributed exclusively to the use of
opioid analgesics, it would seem good practice to consider
avoiding the use of known immunosuppressive opioids in the criti-
cally ill patient, particularly those known to have any degree of
immunosuppression. Consequently, we may need to consider a
further factor when selecting opioids for use in certain groups of
patients.
Conclusion
It is the responsibility of all medical professionals to consider
methods of minimizing hospital-acquired infections which are a
common problem for patients and pose a significant burden on
healthcare resources. Anaesthetists are involved in the care of sur-
gical patients when they are at their most vulnerable; exposed on
an operating table and unable to care for themselves. During this
perioperative period, anaesthetists should use all possible measures
to limit the risk of infection. Appropriately timed and targeted
antibiotic prophylaxis can significantly reduce this risk. Other strat-
egies have growing evidence and consideration should be made to
new research as it emerges.
Conflict of interest
None declared.
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Please see multiple choice questions 1 –4.