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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 - Mycobacterium abscessus > Mycobacterium chelonae, Mycobacterium fortuitum * 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] - minimal clear drainage for 3 days after surgery not uncommon - erythema & pain at the incision site may not completely resolve in 3 days - if erythema & pain increase or new incisional drainage at surgical site post-op is noted, concern for a developing infection is warranted [4,20] 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 - clarithromycin, amikacin, & moxifloxacin for Mycobacterium infection [19] - otherwise, antimicrobial therapy not necessary with limited localized involvement & no systemic signs or symptoms [11,12,13] - prevention: [21] - 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 - nasal swab screening for S. aureus ~2 weeks before surgery - 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. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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
  19. Padilla P, Ly P, Dillard R, Boukovalas S et al Medical Tourism and Postoperative Infections: A Systematic Literature Review of Causative Organisms and Empiric Treatment. Plast Reconstr Surg. 2018 Dec;142(6):1644-1651. PMID: 30489537
  20. Seidelman J, Anderson DJ. Surgical site infections. Infect Dis Clin North Am. 2021;35:901-929. PMID: 34752225
  21. Seidelman JL, Mantyh CR, Anderson DJ. Surgical site infection prevention: a review. JAMA. 2023;329:244-252. PMID: 36648463