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surgical site infection

Occurs within 30 days of surgical procedure. Involves surgical field. Etiology: - risk factors - history of skin infection [3] - tobaccoism (smoking) - older age - immunosuppression* - duration of preoperative hospitalization - malnutrition, recent weight losss - cancer - shaving of hair - hypoxia - hypothermia - hyperglycemia - postoperative blood transfusion - Staphylococcus aureus carrier - inadequate surgical scrub, poor surgical technique - inappropriate use of antimicrobial prophylaxis - self-reported penicillin allergy associated with increased risk for surgical site infection [14] - risk factors for MRSA [2] - impaired functional status is a strong independent predictor - more severe wound - obesity - diabetes, postoperative hyperglycemia - pre-existing indwelling urinary catheter - longer duration of surgery - organisms - Staphylococcus aureus is the most common pathogen - erysipelas caused by group A streptococci (case of venous procedure) [17] - sharply demarcated erythema of the skin * intraoperative dexamethasone (used to prevent postoperative nausea/vomiting) does not predispose to surgical-site infections Epidemiology: 1) overall incidence 1.2% 2) risk maximum at 65 years of age, less in younger & older patients Clinical manifestations: - most begin within 30 days of surgery or within 90 days after implant [4] - may be subtle [4] Laboratory: - culture of wound drainage material, purulent fluid or infected deep tissue [4] * superficial wound swab cultures are likely to represent skin or wound colonization [4] Radiology: - CT if deep incisional infection or abscess suspected - findings in patients with implants or prosthesis, generally non specific [4] Management: - treatment of deep incisional surgical site infections - surgical debridement with removal of necrotic tissue - abscess drainage - specific antimicrobial therapy [4] - penicillin-based antibiotic for erysipelas [17] - sharply demarcated raised superficial erythema (salmon red) of the skin - otherwise, antimicrobial therapy not necessary with limited localized involvement & no systemic signs or symptoms [11,12,13] - prevention: - patients should shower or bath before surgery [10] - surgical site should not be shaved [10] - use triclosan-coated sutures for all surgery [10] - antimicrobial prophylaxis 30-60 minutes before surgical incision - vancomycin or fluoroquinolone may be administered 10-120 minutes before surgical incision - maintain therapeutic levels throughout the procedure - stop prophylactic antibiotics when the procedure ends [4] - postoperative antibiotic prophylaxis is associated with risks for acute kidney injury & C difficile colitis, without preventing surgical-site infections [16] - avoid perioperative shaving of hair [4,5] - use chlorhexidine-based skin preparation [4] - use alcohol-based antiseptic [NEJM knowledge+ no reference] - administration of supplemental oxygen is controversial - glycemic control - postoperative glycemic control (< 180 mg/dL) [4] - intensive perioperative glycemic control [10] - apparently not routine [NEJM knowledge+ no reference] - tobacco cessation 30 days prior to surgery [4] - bundle to screen for Staphylococcus aureus, decolonize carriers, & target antibiotic prophylaxis reduces surgical site infections by ~40% [7] - nasal samples for Staphylococcus carrier state - Staphylococcus carriers receive intranasal mupirocin & are bathed with chlorhexidine gluconate for up to 5 days before surgery - MRSA carriers receive vancomycin plus cefazolin or cefuroxime for perioperative prophylaxis - MSSA carriers & noncarriers receive cefazolin or cefuroxime [7] - negative-pressure wound therapy may diminish risk of surgical site infection with primarily closed wounds with poor tissue perfusion due to surrounding soft tissue or skin damage [10]

General

wound infection postoperative complication

References

  1. Journal Watch 25(9):71, 2005 Kaye KS, Schmit K, Pieper C, Sloane R, Caughlan KF, Sexton DJ, Schmader KE. The effect of increasing age on the risk of surgical site infection. J Infect Dis. 2005 Apr 1;191(7):1056-62. Epub 2005 Feb 24. PMID: 15747239 - Talbot TR, Schaffner W. Relationship between age and the risk of surgical site infection: a contemporary reexamination of a classic risk factor. J Infect Dis. 2005 Apr 1;191(7):1032-5. Epub 2005 Feb 24. PMID: 15747235
  2. Chen TY, Anderson DJ, Chopra T, et al. Poor functional status is an independent predictor of surgical site infections due to methicillin-resistant Staphylococcus aureus in older adults. J Am Geriatr Soc 2010; 58(3):527-532. PMID: 20158557
  3. Faraday N et al. Past history of skin infection and risk of surgical site infection after elective surgery. Ann Surg 2013 Jan; 257:150. PMID: 22634899
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021.
  5. Anderson DJ. Surgical site infections. Infect Dis Clin North Am. 2011 Mar;25(1):135-53. PMID: 21315998
  6. Anderson DJ et al SHEA/IDSA Practice Recommendation. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology. June 2014. 35(6) PMID: 24799638 http://www.jstor.org/stable/full/10.1086/676022
  7. Schweizer ML et al Association of a Bundled Intervention With Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery. JAMA. 2015;313(21):2162-2171 PMID: 26034956 http://jama.jamanetwork.com/article.aspx?articleid=2300601 - Malani PN Bundled Approaches for Surgical Site Infection Prevention. The Continuing Quest to Get to Zero. JAMA. 2015;313(21):2131-2132. PMID: 26034954 http://jama.jamanetwork.com/article.aspx?articleid=2300579
  8. Anderson DJ, Podgorny K, Berrios-Torres SI et al Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S66-88. PMID: 25376070
  9. de Mestral C, Nathens AB. Prevention, diagnosis, and management of surgical site infections: relevant considerations for critical care medicine. Crit Care Clin. 2013 Oct;29(4):887-94. Review. PMID: 24094383
  10. World Health Organization (WHO) WHO recommends 29 ways to stop surgical infections and avoid superbugs. WHO News Release, Nov 3, 2016 http://www.who.int/mediacentre/news/releases/2016/recommendations-surgical-infections/en/ - Allegranzi B, Zayed B, Bischoff P et al New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence- based global perspective. Lancet Infectious Diseases. Nov 2, 2016 PMID: 27816414 http://thelancet.com/journals/laninf/article/PIIS1473-3099(16)30402-9/fulltext - Allegranzi B, Bischoff P, de Jonge S et al New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infectious Diseases. Nov 2, 2016 PMID: 27816413 http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30398-X/fulltext
  11. Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014 Jun 21; 59:147 PMID: 24947530
  12. Anderson DJ. Surgical site infections. Infect Dis Clin North Am 2011 Feb 15; 25:135 PMID: 21315998
  13. NEJM Knowledge+ Question of the Week Nov 7, 2017 https://knowledgeplus.nejm.org/question-of-week/534/
  14. Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis. 2018 Jan 18;66(3):329-336 PMID: 29361015 https://academic.oup.com/cid/article/66/3/329/4372047 - Dellinger EP, Jain R, Pottinger PS. The influence of reported penicillin allergy. Clin Infect Dis. 2018 Jan 18;66(3):337-338 PMID: 29361016 https://academic.oup.com/cid/article/66/3/337/4372057
  15. Garner BH, Anderson DJ. Surgical Site Infections: An Update. Infect Dis Clin North Am. 2016 Dec;30(4):909-929. Review. PMID: 27816143
  16. Branch-Elliman W, O'Brien W, Strymish J et al Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg. Published online April 24, 2019 PMID: 31017647 https://jamanetwork.com/journals/jamasurgery/fullarticle/2731307 - Hawn MT, Knowlton LM Balancing the Risks and Benefits of Surgical Prophylaxis. Timing and Duration Do Matter JAMA Surg. Published online April 24, 2019. PMID: 31017641 https://jamanetwork.com/journals/jamasurgery/fullarticle/2731303
  17. NEJM Knowledge+ Question of the Week. Sept 3, 2019 https://knowledgeplus.nejm.org/question-of-week/536/ - Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996 Jan 25; 334:240. PMID: 8532002 https://www.nejm.org/doi/full/10.1056/NEJM199601253340407 - Stevens DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014 Jun 21; 59:e10. PMID: 24947530
  18. Corcoran TB et al. Dexamethasone and surgical-site infection. N Engl J Med 2021 May 6; 384:1731 PMID: 33951362 https://www.nejm.org/doi/10.1056/NEJMoa2028982