REVIEW

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Perspectives in Prevention and

Treatment of Surgical Site Infection
A Narrative Review of the Literature

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Address correspondence to:

David Leaper, MD, ChM, FRCS, FACS,
FLS
Professor in Clinical Studies
School of Human and Health
Sciences
University of Huddersfield
Queensgate, Huddersfield HD1 3DH
United Kingdom
profdavidleaper@doctors.org.uk

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From the 1University of Huddersfield,

Queensgate, UK; 2University of
New Mexico School of Medicine,
Albuquerque, NM; 3Northwestern
University, Chicago, IL; 4Medical
University of Vienna, Vienna, Austria

Abstract: Health care-associated infections (HCAIs) are infections acquired

through contact with any aspect of health care. They can cause minor
complications or serious disability or death, and can involve a wide variety
of resistant or emergent organisms. Surgical site infections make up approximately one-fifth of HCAIs, and at least 5% of patients undergoing
open surgery develop an SSI. Surgical site infections are probably the most
preventable HCAI but have received the least attention; although that is
changing with increased surveillance and public awareness of published
data of individual specialty and hospital incidence rates. Surgical site infection continues to be a complication of surgical care. These infections
span a continuum of severity with some being quite innocent and easy to
manage, while others are life-threatening. Considerable evidence provides
direction in the prevention of SSI (eg, systemic antibiotic prophylaxis) but
many preventive strategies need better definition, with additional clinical
studies. When SSI occurs, the clinician needs to quickly recognize it and
tailor management to the specific needs of the patient. In general, drainage, debridement, and specific antibiotics for the putative pathogen are
the hallmarks of management.

WOUNDS 2013;25(11):313-323

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David Leaper, MD, ChM, FRCS, FACS, FLS1; Donald Fry, BSc, MD,
FACS2,3; Ojan Assadian, MD, DTMH4

Key words: surgical site infection, treatment, prophylaxis

Disclosure: The authors disclose

no financial or other conflicts of
interest.

ealth care-associated infections (HCAIs) are infections that are acquired through contact with any aspect of health care. They can
cause minor complications or serious disability or death, and can involve a wide variety of resistant or emergent organisms.1 Examples of HCAIs
include respiratory tract infections such as hospital- and ventilator-associated
pneumonias complicated by Gram-negative, nonfermenting bacilli that are resistant to almost all classes of antibiotics; and urinary tract infections caused
by microorganisms resistant to the quinolones and increased by the presence
of a catheter, mostly involving coliforms that can produce extended spectrum beta-lactamases (and, more worryingly, metallo-beta-lactamases, such as
the newly described New Delhi-metallo-beta-lactamase 1 [NDM-1],2,3 making bacteria resistant to a wide range of beta-lactam antibiotics, including all
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Surgical Site Infection

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Definitions. Many surgeons are unaware of their SSI

rate because of nonexisting or suboptimal surveillance
and inconsistent definitions. The first realistic survey of
SSI was not sensitive, as only the presence of pus was
used for the identification of SSI.14 Wounds are now categorized into clean (no viscus opened), clean-contaminated (viscus opened, minimal spillage), contaminated
(viscus opened with spillage or presence of inflammatory disease), and dirty (pus or perforation present or
incision made through an abscess).15 This categorization
was based on a theoretical division of potential for SSI
development. It is flawed by the failure to include patient risk and the use of prosthetic materials, which may
dramatically impact the risk for SSI in procedures within
the clean category. Furthermore, because of the constant
introduction of new operative techniques, particularly
endoscopic procedures and the rise of natural orifice
transluminal endoscopic surgery (NOTES) this categorization is becoming increasingly blurred and may not be
applicable.
It is critical that standard definitions are used to allow studies to be comparable. Analysis of outcomes and
comparison between studies requires exact definitions
of patients characteristics and their risk stratification,
based on comorbid medical conditions. In addition to
demographic details, clinical manifestations of SSI vary
epidemiologically depending on the onset of infection.
The Centers for Disease Control and Prevention (CDC)
is the most widely used and comprehensive definition
(Table 1).16 This system only gives categorical data which
does not reflect the severity of an SSI. In brief, SSIs are
categorized at 3 levels: superficial incisional, in the skin
or subcutaneous tissues; deep incisional involving fascia
or muscle; and deep/organ space, involving, for example,
the pleura after lung surgery or the liver after hepatic resection. Most SSIs fall into the superficial group and the
less common deep/organ space infections are the most
serious or life threatening. The categories are open to
interpretation and may depend on the attending physicians diagnosis. By contrast, the ASEPSIS scoring method

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wound discharge (eg, after open hernia surgery) to being life threatening (eg, mediastinitis and sternal wound
infection).12 In between, HCAIs contribute to scars which
may be cosmetically unacceptable to the patient, cause
pain, require prolonged length of hospital stay with the
incurred expenses, and result in poor emotional well-being for the patient.13

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carbapenems). Infections involving prosthetic materials,

as diverse as hip replacement or vascular grafts, are caused
mainly by multiple-resistant coagulase negative staphylococci; bacteraemias and complicated skin and soft tissue
infections are associated with highly virulent meticillin
sensitive Staphylococcus aureus (MSSA) or meticillin resistant Staphylococcus aureus (MRSA) strains; and emergence of Clostridium difficile is the underlying cause of
antibiotic related colitis.4
Among HCAIs, surgical site infection (SSI) is of greatest
recent concern.5 Surgical site infections can be caused
by many organisms which may be antibiotic resistant.
Patients who develop HCAIs usually have related treatments or underlying contributory illnesses, but the misuse of antibiotics is a key factor in all cases. All HCAIs
can be prevented or reduced by attention to known risk
factors. The cost of HCAIs to health care is large,6,7 and
has prompted many initiatives associated with extensive
international media and political campaigns.
The bacteria involved in SSIs include those carried by
the patients themselves (endogenous flora), and those
that may be introduced in the operating room (exogenous flora).5 Native colonization (the source of infection),
is determined through the type of surgery (eg, coliforms
and anaerobes in colorectal surgery), although staphylococci predominates overall from the bacterial reservoir
in skin. Gram-positive pathogens from airborne microbes
and the surgical team (due to glove punctures during surgical procedures or from suboptimal sterilization of instruments) may be infrequent sources of contamination
of the surgical site. Opportunistic and resistant organisms
may be cultured from infections after selected operations
(eg, prosthetic surgery). All patients are at risk of acquiring resistant organisms, particularly if they have an underlying debilitating illness, poor compliance with accepted
prevention guidelines, or they have health care-associated exposure (ie, prior hospitalization or admission to a
chronic care facility) that colonizes them with unusually
resistant bacteria.
Surgical site infections make up approximately a fifth
of the HCAIs in the United Kingdom, and at least 5% of
patients undergoing open surgery in the UK develop an
SSI.8 Surgical site infections are probably the most preventable HCAI but have received the least attention; although that is changing with increased surveillance and
public awareness of published data of individual specialty
and hospital incidence rates.9-11 Surgical site infections
are associated with more than one-third of postoperative
related deaths ranging from relatively trivial, short-lived,

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Table 1. Summary of CDC definition of SSI.

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Superficial Incisional SSI

Infection occurs within 30 days after the operation;
infection involves only the skin or subcutaneous tissue; and
at least 1 of the following:
o purulent drainage (culture documentation not required);
o organisms isolated from fluid/tissue of superficial incision;
o at least 1 sign of inflammation (eg, pain or tenderness, induration, erythema, local warmth of the wound);
o wound is deliberately opened by the surgeon; or
o surgeon or attending physician declares the wound infected.
A wound is not considered a superficial site infection if there is:
o a stitch abscess present;
o infection of episiotomy or circumcision site;
o infection of a burn wound; or
o incisional SSI that extends into the fascia or muscle.

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Deep Incisional SSI

Infection occurs within 30 days of operation or within 1 year if an implant is present;
infection involves deep soft tissues (eg, fascia and/or muscle) of the incision; and
at least 1 of the following:
o purulent drainage from the deep incision but without organ/space involvement;
o fascial dehiscence or fascia is deliberately separated by the surgeon due to signs of inflammation;
o deep abscess is identified by direct examination, during reoperation, by histopathology, or by radiologic examination;
or
o surgeon or attending declares deep incisional infection is present.

Organ/Space SSI
Infection occurs within 30 days of operation or within 1 year if an implant is present;
infection involves anatomic structures not opened or manipulated by the operation; and
at least 1 of the following:
o purulent drainage from a drain placed by a stab wound into the organ/space;
o organisms isolated from organ/space by aseptic culturing technique;
o identification of abscess in the organ/space by direct examination, during reoperation, or by histopathological or radiological examination; or
o diagnosis of organ/space SSI by surgeon or attending physician.

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Adapted from16 Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a
modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606-608.

for postoperative wound infections gives interval data17

but, despite its simplicity, has only been used in research
trials. In todays world of same-day surgery and fast-track
postoperative recovery ASEPSIS is less easy to use and its
validity may be questioned.18
Surveillance, incidence, and cost. Surveillance is
equally critical to standard definitions. The CDC definition requires surveillance for infection be undertaken
for 30 days for infection in soft tissues and up to a year
for orthopedic and vascular prosthetic surgery. Again, the
uptake of same-day surgery and fast-track postoperative
recovery has affected the accuracy of surveillance figures,
which were largely based on inpatient data. Postdischarge
surveillance must now be included since the majority of
SSIs have a mean time to presentation of 8-10 days and
are not apparent until after the patient has left the hospi-

tal. Ideally, surveillance should include a trained, blinded

observer using agreed-upon definitions rather than surrogate automated methods.18-24 Accurate surveillance,
including postdischarge data, can inform and influence
practice by allowing valid comparisons.25,26 In some countries, SSI surveillance is becoming mandatory. The methodology used has to be pragmatic and mostly depends on
assessment at discharge, or telephone and questionnaire
follow-up, but in research trials individual follow-up by
direct observation is required for accuracy. Some areas of
surgery have a low incidence of SSI, such as laparoscopic/
endoscopic surgery.27
There have been several predictive indices for SSI.The
Study on the Efficacy of Nosocomial Infection Control
(SENIC) included contaminated wound, diagnosis at discharge, duration of surgery, and abdominal surgery; and
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Prevention of Surgical Site Infection

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Level I evidence. Many national and international

guidelines present the best available evidence for the prevention of SSI. In the United Kingdom, for example, there
are 2: from the National Institute for Health and Clinical Excellence (NICE)33 and the Scottish Intercollegiate
Guideline Network (SIGN).34 In the United States, similar
quality improvement programs include the Surgical Care
Improvement Project (SCIP)35 and the National Surgical
Quality Improvement Program (NSQIP).36,37 The principal
recommendations have been collated into a care bundle
by the Department of Health of the United Kingdom.38
The concept of using this best evidence should summate
the effects of the interventions, but success depends on
the quality of compliance. The longer-term follow-up of
NICE, SCIP, and NSQIP and their respective degree of
compliance, will determine how effective they are.
The effectiveness of these national guidelines and performance measures to improve the rates of SSI remains
to be seen. Three recent studies have demonstrated no
improvement in SSI rates despite national efforts in the
US to enforce compliance with SCIP measures.39-41 Hospitals with high rates of compliance do not have better SSI
rates than those with less compliance. It is important to
emphasize that SSI rates are influenced by multiple clinical variables and not only those articulated by national
agencies. The recommendations by NICE and SCIP are
clinically valid, but issues such as poor surgical technique
and suboptimal compliance, along with the many other
variables that influence SSI, will negate the benefits that
should be seen. Clinicians and government policy makers
must understand the complexity of SSI as a clinical outcome; recommendations focused upon a limited number
of practices are only a starting point in prevention and, by

themselves, may not influence overall outcomes.42

Common to all of the guidelines and performance
measures is the level I evidence supporting the rational
use of antibiotic prophylaxis and the avoidance of razors
for hair removal. Considerable level I evidence shows antibiotic prophylaxis significantly reduces SSIs after clean
prosthetic, clean-contaminated, and contaminated operations.33-38 Prophylaxis should be initiated within the immediate preincisional period of time (< 60 minutes before
incision) and the antibiotic that is chosen should cover
the organisms that are likely to be encountered. The selected antibiotic may depend on local resistance patterns,
and guidance of a local formulary may be necessary. Usually a single-dose of antibiotic at, or immediately before,
the induction of anesthesia is sufficient. Dirty operations,
where infection already exits, will need a longer course
of antibiotics that acts both as therapy and prophylaxis.
During the past 3 decades, prevention of SSI has relied almost entirely on the availability of effective perioperative antibiotic prophylaxis due to its high level of
evidence. For the same reason, antibiotic prophylaxis has
also been used for treatment of infections after clinical
presentation. For example, in vascular surgery, 10 randomized controlled trials (RCTs) have been undertaken
comparing systemic antibiotics vs placebo, and a systematic review and meta-analysis43 demonstrated a consistent
benefit in reduction of SSI in 1297 patients relative risk
(RR fixed, 0.25; (95% CI, 0.17 to 0.38; P = 0.0001). Although no single study demonstrated a statistically significant reduction in early vascular graft infection, the pooled
results of these 10 RCTs appeared homogeneous with a
reduction in early graft infection evident on meta-analysis (RR fixed, 0.31; 95% CI, 0.11 to 0.85; P = 0.02). There
are, however, 2 aspects of these results which need to be
highlighted. First, 6 of the 10 RCTs included a case-mix of
patients with both prosthetic and vein grafts. If the results
of the prophylactic effect of antibiotics are stratified by
the type of graft, the RR for wound infection with prosthetic graft is nonsignificant at 0.51 (95% CI, 0.24 1.11).
The administration of prophylactic antibiotics yielded a
significant benefit only for patients with vein grafts (RR =
0.13; 95% CI, 0.04 0.41). Therefore, in vascular surgery,
evidence for the prophylactic effect of systemic antibiotics exists only for patients with vein grafts, who are at
lower risk of infection, compared to patients receiving
prosthetic material. Second, the meta-analysis is based on
10 studies that compared the effect of systemic antibiotics with placebo, conducted in the early to mid-1980s.
Resistance of Staphylococcus aureus (the most fre-

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the National Nosocomial Infections Surveillance index included contaminated wound, the American Society of Anesthesiologists Physical Status classification system grade,
and duration of surgery. They have been compared28,29
and both were found capable of predicting SSI.
Apart from the unrecorded indirect costs related to loss
of productivity, reduced quality of life, and litigation, the
actual cost of an SSI can involve additional inpatient treatment and procedures that can run into many thousands
of pounds.30 The morbidity and mortality rates which follow sternal infection after cardiac surgery are just one
example.31 There is a paucity of prospective cost-benefit
analysis of the SSI, but retrospective analyses clearly identify that the economic costs of SSI are substantial.32

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Table 2. Factors implicated in a higher risk of

surgical site infection.*

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i. Patient factors
age sex obesity smoking
immunosuppression
steroids, cancer, anticancer therapy (chemo and radiotherapy), HIV
nutritional indices
metabolic factors
diabetes mellitus, hepato0renal failure, serum albumin,
haemoglobin

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ii. Preoperative factors

nasal decontamination
mechanical bowel preparation
skin preparation (surgical teams hands patients skin)
iii. Operative factors
previous surgery
antiseptic-impregnated incise drapes
length and complexity of operation
operating surgeon
blood loss
antimicrobial sutures
diathermy

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quent bacterial organism to cause vascular infections)

to methicillin was first noted clinically in 1961.44 In the
US, methicillin-resistant Staphylococcus aureus (MRSA)
only emerged in the period 1975 to 1981 in tertiary care
centers. The percentage of major US acute care hospitals
reporting greater or equal to 50 MRSA cases per year increased from 18% in 1987 to 32% in 1989.45 Therefore, the
result of meta-analyses of RCTs chiefly investigating the
beta-lactam antibiotics which demonstrated efficacy of
antibiotic prophylaxis need to be noted with caution today, as MRSA already has become the most frequent cause
of skin and soft tissue infections presenting to emergency
departments in the US.46 Although speculative, it remains
questionable if a meta-analysis of these RCTs would yield
significance again if conducted with the current rigor and
epidemiologic situation.
The studies which give evidence that the use of razors
to remove hair preoperatively cause infection are primarily from 30 years ago, but most guidelines suggest that if
hair has to be removed, it should be done with a disposable clipper head, close to the time of surgery.33,47 These
studies are robust enough to give level I evidence. The
damage caused to skin by shaving too long before surgery
encourages the growth of organisms, which increase the
risk of SSI.
Also common in the guidelines and performance measures are methods to optimize the physiology of the host
at the time of the operations; that is, avoidance of hypothermia, adequate glycemic control, and supplemental
oxygen administration.The clinical value of avoiding perioperative hypothermia was first realized more than 15
years ago48 and there has since been many adequate RCTs
confirming the relevance of warming in the prevention
of SSI,23 which led to a NICE guideline.49 The pathophysiological benefit has also been well examined.50
From the analysis of secondary outcomes in clinical
trials, it has been suggested that patients who have diabetes and whose blood sugar is out of control are more
at risk of SSI.This is supported by experimental evidence
that many physiological mechanisms are impaired by
hyperglycemia. Most guidelines suggest blood glucose
should be tightly controlled in patients with diabetes.38
However, it has been convincingly shown that following
cardiac surgery, even in patients without diabetes, poor
glucose control is associated with poor wound healing,
as well as SSI in sternal wounds and in leg wounds after
harvest of saphenous vein.51 The maintenance of blood
glucose has been adopted as standard practice in cardiac
surgery and it is unlikely that RCTs will be undertaken

iv. Postoperative factors

antiseptic lavage of wounds and cavities
antimicrobial dressings
supplemental oxygen in recovery
v. Other factors observed but with varying levels of evidence
theatre environment
preoperative showering
theatre wear
minimising movement in the OR
banning of jewellery and nail polish
drapes and gowns
wound drainage
*The relevance of many of these factors needs revisiting
with adequate trial design.

Adapted from85 Fry DE. Surgical site Infection. In: Fry DE, ed. Surgical Infections. London, UK: JP Medical Publishers Ltd;2013:4962.

to further prove this point. However, glycemic control in

other fields of major surgery remains unproven, and tight
glycemic control in patients without diabetes remains an
area to be explored with RCTs. This may be especially
true in trauma patients and patients with major surgical
interventions, where hyperglycemia is part of the normal
metabolic response to trauma and major surgical stress.
Intraoperative and immediate postoperative use of
supplemental oxygen in the prevention of SSI discussed in
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ject of a meta-analysis showing it does not reduce the

risk of SSI.60 However, this finding, like many Cochrane
Collaboration meta-analyses, needs clinical interpretation prior to implementation for all patients. Since
the 1930s, it has been shown that mechanical bowel
preparation alone does not reduce SSI rates.61 Mechanical preparation with the use of orally-administered and
poorly absorbed antibiotics (eg, neomycin and erythromycin) has been shown in prospective, randomized,
placebo-control trials to reduce SSIs.62,63 Two separate
meta-analyses show that mechanical bowel preparation, when combined with the oral antibiotic bowel
preparation and systemic prophylactic antibiotics, do
reduce SSI in elective colon resection when compared
to mechanical bowel preparation and systemic antibiotics only.64, 65
Skin preparation is routine prior to surgery but there
has been little clear evidence demonstrating which
antiseptic preparation is the best. Chlorhexidine has
been a popular skin preparation, but in a concentration
of 2% in combination with 70% isopropanol it has been
shown to significantly reduce superficial and deep
SSIs.66 The use of topical antiseptics for preparation of
the surgical teams hands, and as a preoperative wash
for patients, has a good evidence base which deserves
recognition.67-69 In view of the continued rise of antibiotic resistance, the use of antiseptic dressings and
prophylactic antiseptic lavage for wounds and cavities
bears reconsideration in future clinical trials, as well as
reconsideration as a treatment for established SSIs.33,57
Intraoperative factors that might relate to the incidence of SSI are traditionally observed and operating
room discipline is long established, with a reluctance
to change protocol without clear evidence. Operating room environment control has to be placed in this
category. Some of these factors do have basis and are
included in the risk factor prediction indices.28,29 The
NICE guideline, having reviewed the old trials33 of antiseptic impregnated drapes, recommended they be
used as nonimpregnated drapes, as there clearly was
an increased risk of SSI associated with their use. By
contrast, the guideline could not recommend, for example, the use of diathermy to reduce the risk of SSI.
Evidence that the use of antimicrobial sutures can reduce SSIs is increasing; this has been found in clean,
prosthetic, abdominal and thoracic surgery,18,57,70-73 and
a meta-analysis has now been published which shows
a level I evidence-base of the efficacy of antimicrobial
sutures for the prevention of SSI.74 Again, we are see-

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this review because of the conflict in the results of RCTs.

Considerable experimental evidence supports the use of
supplemental oxygen to prevent incisional infection.52
Two RCTs have demonstrated significant reductions in SSI
by the use of intraoperative and immediately postoperative
oxygen supplementation (FiO2= 0.8).53,54 A single RCT has
demonstrated an increase in SSI rates with supplemental
oxygen.55 While the theoretical arguments to support supplemental oxygen are abundant, additional studies appear
to be warranted before guidelines or performance measures can be applied for the prevention of SSI.
Other evidence and risk factors. Many guidelines and
reviews have listed other factors (Table 2) that can influence the incidence of SSI but most are of level II evidence
base at best.56,57 Many are anecdotal, others have been
identified by logistic regression analysis in trials and audit
of SSI; and others by meta-analysis (Table 1).
Many of these reports suggest that being male or being
elderly is associated with an increased risk of SSI, although
1 cohort study found a decreasing risk after 65 years.58
Obesity is also cited in studies as being an important, independent risk factor.23,33 In addition, many patient-related
factors, including smoking, have a strongly supportive experimental base which has not been proven conclusively
in clinical trials. This also applies to immunosuppressive,
nutritional, and metabolic factors outside the scope of
this article. Serum albumin is an example of a factor often
ascribed significance for being an independent clinical
risk factor, but it has not been clearly defined as such in
prospective trials. A low value is associated with uncertain causation and may not reflect nutritional deficiencies in the developed world. However, experimental data
shows it is a strong marker of poor healing; but in clinical practice, the serum albumin value is usually related to
confounding factors associated with severe systemic illness, such as cancer cachexia or sepsis.The NSQIP places
emphasis on low albumin being a predictor of surgical
complications, but only further prospective studies will
confirm its true role as a predictor of SSI.
Nasal decontamination (suppression) of Staphylococcus aureus was introduced by infection prevention
programs in an effort to reduce the risk of MRSA. Both
MSSA and MRSA can cause SSI, and staphylococci remain
overall the commonest infecting organisms. Nasal suppression has not been recommended by NICE or SCIP to
reduce SSI, but there is now evidence that this is useful; it
is important to remember that MSSA infections are just as
important to prevent.59
Mechanical bowel preparation has been the sub318

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Table 3. Indications for antibiotics in surgical

practice for treating surgical site infection.
Cellulitis
Lymphangitis
Bacteremia
Systemic inflammatory response and multiple organ dysfunction syndromes
Definite pathogens (eg, beta-hemolytic streptococcus)
Large numbers of organisms (eg, critical-colonisation local infection)
Poor host defenses (eg, immunosuppression, diabetes)

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be desirable in specific cases, but most superficial and

deep SSIs do not require antibiotics when drainage and
debridement is prompt. Antibiotics are warranted when
local cellulitis or wound necrosis is present (Table 3). For
staphylococcal SSI, microbiological culture and sensitivities may be needed to direct antibiotic coverage for MSSA
or MRSA. With community-associated MRSA, clindamycin,
trimethoprim/sulfamethoxazole, or doxycycline may be
sufficient. Clinicians are advised to beware the clindamycin-sensitive but erythromycin-resistant MRSA since
many of these organisms develop induced resistance to
clindamycin during therapy. For conventional health careassociated MRSA, the use of vancomycin, linezolid, or daptomycin may be appropriate. Gram-negative infections
need culture guidance, and when infections follow colonic procedures, the coverage of enteric anaerobic species, with use of metronidazole for example, is necessary.
The organ/space infection may require more aggressive
measures.When there is necrotizing infection and separation of the fascia, debridement is essential. Debridement
of these infections can be extensive with considerable
loss of fascia and associated muscle. Invasive necrotizing
infections within the surgical incision have become an increasing problem with the community-associated MRSA
pathogens.75 Polymicrobial necrotizing infections will
be seen following gastrointestinal contamination of the
surgical site. Inadequate debridement leads to additional
debridement and increased fascia and muscle loss. Temporary absorbable meshes may be required for abdominal
wounds when there is loss of fascia. High rates of ventral
hernia are seen following the scenario of necrotizing infection and absorbable meshes in the abdominal wall.
Intra-abdominal abscesses may require percutaneous
drainage procedures. Management of the source of the organ/space infection, such as a leaking intestinal suture line,
may require surgical management to control the source of
continued contamination. Infected prostheses generally require removal, although these infections of vascular grafts,

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ing the return of antiseptics as a first line treatment of

managing SSI.
Many of the remaining factors listed in Table 1 have
been challenges, although many of them are part of the
traditional lore of clinical surgery. Guidelines continue
to support gowns and drapes, appropriate use of surgical gloves, and reduction of movement in the operating
room. Some have advocated the banning of jewelry and
nail polish, but the evidence to support these policies are
lacking. Preoperative showering and the value of wound
drains are areas with supportive opinions but need additional research to validate their application.
Other strategies used in infection prevention, such
as maximal sterile barrier precautions; routine change
of surgical gloves before graft implant; performing surgical procedures in HEPA filtered, turbulence-free, laminar air-flow, ventilated operation rooms; implementation
of perioperative surgical check lists; or the choice and
concentration of pre-operative skin antiseptics and how
they should be used, have not been studied in depth and
indicate areas for future research.

Treatment of Established Surgical

Infection and SSIs

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Essential to treating surgical infection, and superficial

and deep SSIs, is to open the area of infection and to drain
pus.With deep SSI, this may require opening and draining
the entire incision, while superficial SSI may only require
a limited area of drainage. Fibrinous debris is removed
and any remaining sutures or staples in the area of infection should also be removed.The open wound commonly
needs specific wound care to allow healing by secondary intention, although delayed primary or secondary closure may be feasible in selected cases. The open wound
is managed with interactive moist dressings and wound
desiccation should be avoided. The use of topical antimicrobial therapy is largely chosen by physician preference
and remains an area for additional comparative investigations of alternative agents. The concerns that antiseptics
may induce bacterial resistance to themselves, or even to
antibiotics, with the risks of transmission, are unfounded.
This is either because their mode of action is not suitable
for bacteria to develop resistance, or because the clinically used high concentrations of antiseptics (which often
surpass the required minimum inhibitory concentrations
by 500 to 1,000 fold), are still able to rapidly kill off pathogens even if they have developed a decreased susceptibility against the applied antiseptic.74
Topical negative pressure wound management may

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Conclusion

Surgical site infection continues to be a complication

of surgical care. These infections span a continuum of severity with some being easy to manage while others are
life-threatening. Considerable evidence provides direction in the prevention of SSI such as systemic antibiotic
prophylaxis, but many preventive strategies need better
definition, with additional clinical studies. When SSI occurs, the clinician needs to be able to quickly recognize it
and tailor management to the needs of the patient. In general, drainage, debridement, and specific antibiotics for
the putative pathogen are the hallmarks of management.

References
1.

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Microbiological investigations may support the diagnosis of SSI and surgical infections, provided specimens
are obtained appropriately. Thereby, microorganisms that
are potentially causative for infection are yielded, and not
colonized flora, which have no relevance for a suspected
infection. Optimal results are achieved from specimens
obtained directly from the infection site. Such material
may include explanted grafts, extra- or intra-operatively
obtained tissue biopsies from the infected area, and material aspirated from peri-graft fluid collection. Indirectly
obtained material, such as blood cultures, may also yield
important information. However, blood cultures may often be negative, particularly in late-onset infection, but
are more frequently positive in early-onset infection.76
Specimens may be processed using a number of techniques such as direct streaking swabs on agar plates, broth
culture, homogenization of tissue specimens with serial
dilution techniques, and sonication of the specimen to
enhance the recovery of biofilm-forming organisms from
graft or infected material.77 The report of processed microbiological specimens is decisive for a valuable evaluation
of therapy and clinical results.78,79 The demonstration of
specimens relevance from the pre-, intra- and postoperative phases is considered most valuable, if feasible and possible.80 Relevant preoperative samples include blood cultures taken from central and peripheral venous catheters
or direct vein puncture, wound specimens, drainage fluid,
nose and throat swabs in the case of MRSA colonization,
and urinary samples. In any case, all responsible microorganisms should be classified according to their type (eg,
Gram-positive or -negative, fungi, etc.) and specific therapy antibiograms offered for highly virulent microorganisms (eg, Pseudomonas aeruginosa). Careful assessment
is needed for microorganisms isolated from overlying
wounds or sinuses, as such microorganisms may represent
colonizing flora, (eg, MRSA), and may be wrongly interpreted as causative agents.76 Relevant intraoperative samples
are standard specimens obtained from the surgical site, the
peri-graft fluid/pus, or explanted prosthetic material.Worth

Microbiological Diagnosis

noting is that a considerable number of specimens may be

negative.81-83 A negative microbiological report, however,
does not exclude an infection. Finally, relevant postoperative samples are blood cultures, drainage fluid, and wound
specimens (eg, those usually taken when there is delayed
wound healing). The development of polymerase chain
reaction methodologies that will provide unique bacterial
species and sensitivity signatures may greatly enhance the
diagnosis of infection and will reduce the number of circumstances where microbiological evaluation of wound
and blood cultures are negative, but clinical infection appears to be present.84

IC

heart valves, and prosthetic joints pose special problems.

Antibiotics are almost always required for organ/space infections, the specific choice of which must be guided by
culture and sensitivity data. Organ/space SSI pathogens are
often staphylococcal but these infections are commonly
associated with resistant organisms from the hospital environment. Antibiotic therapy again must be driven by specific culture and sensitivity data.

320

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