Journal of Hospital Infection (2008) 70(S2) 3–10

Available online at www.sciencedirect.com

www.elsevierhealth.com/journals/jhin

Surgical site infections: epidemiology,

microbiology and prevention
C.D. Owens, K. Stoessel*
Kimberly-Clark Healthcare, Atlanta, GA, USA

KEYWORDS Summary Surgical site infections (SSIs) are defined as infections occurring
Epidemiology; up to 30 days after surgery (or up to one year after surgery in patients
Guidelines; receiving implants) and affecting either the incision or deep tissue at
Surgical site the operation site. Despite improvements in prevention, SSIs remain a
infections; significant clinical problem as they are associated with substantial mortality
Sealant;
and morbidity and impose severe demands on healthcare resources. The
Wound
contamination;
incidence of SSIs may be as high as 20%, depending on the surgical procedure,
Skin asepsis the surveillance criteria used, and the quality of data collection. In many
SSIs, the responsible pathogens originate from the patient’s endogenous
flora. The causative pathogens depend on the type of surgery; the
most commonly isolated organisms are Staphylococcus aureus, coagulase-
negative staphylococci, Enterococcus spp. and Escherichia coli. Numerous
patient-related and procedure-related factors influence the risk of SSI,
and hence prevention requires a ‘bundle’ approach, with systematic
attention to multiple risk factors, in order to reduce the risk of bacterial
contamination and improve the patient’s defences. The Centers for Disease
Control and Prevention guidelines for the prevention of SSIs emphasise the
importance of good patient preparation, aseptic practice, and attention to
surgical technique; antimicrobial prophylaxis is also indicated in specific
circumstances. Emerging technologies, such as microbial sealants, offer
the ability to seal and immobilise skin flora for the duration of a surgical
procedure; a strong case therefore exists for evaluating such technologies
and implementing them into routine clinical practice as appropriate.
© 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

Introduction ‘surgical wound infection’. 1 SSIs are defined as

infections occurring within 30 days after a surgical
The term ‘surgical site infection’ (SSI) was operation (or within one year if an implant is
introduced in 1992 to replace the previous term left in place after the procedure) and affecting
either the incision or deep tissue at the operation
* Corresponding author. Kathleen B. Stoessel, RN, BSN,
MS. 1400 Holcomb Bridge Road, Roswell, GA 30076, site. 2 These infections may be superficial or
USA. E-mail: Kathleen.stoessel@kcc.com (K. Stoessel). deep incisional infections, or infections involving
Charlotte D. Owens, MD, FACOG: 1400 Holcomb Bridge organs or body spaces (Figure 1). 2 SSIs remain a
Road, Roswell, GA 30076, USA. major cause of morbidity and mortality, despite
E-mail: charlotte.owens@kcc.com (C.D. Owens).

0195-6701/$ - see front matter © 2008 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
4 C.D. Owens, K. Stoessel

Fig. 1. Classification of surgical site infections (SSIs) according to the Centers for Disease Control National Nosocomial
Infections Surveillance (CDC NNIS) system. 1 Reproduced with permission from Mangram et al. 2

improvements in infection control techniques and lower incidence of SSIs with minimally invasive
surgical practice, and impose substantial demands procedures include the smaller incision, earlier
on healthcare resources. 2 Continuing vigilance mobilisation, reductions in postoperative pain,
is therefore required to minimise the incidence better preservation of immune system function,
of such infections. This requires a systematic and decreased use of central venous catheters. 6
approach, with attention to multiple risk factors
related to the patient, the procedure, and the
hospital environment. Impact of SSIs on healthcare resources
SSIs impose a substantial clinical burden. Patients
Epidemiology of SSIs with SSIs are more likely to require readmission to
hospital or intensive care unit (ICU) treatment, and
Studies of the epidemiology of SSIs are complicated are at higher risk of death, than those without such
by the heterogeneous nature of these infections: infections. For example, in a case control study
the incidence varies widely between procedures, involving 215 matched pairs of patients with and
between hospitals, between surgeons and between without SSIs, the relative risk for death associated
patients. 3 Data from the United States Centers with SSIs was 2.2 [95% confidence interval (CI):
for Disease Control National Nosocomial Infections 1.1 4.5], and those for readmission and ICU
Surveillance (CDC NNIS) system show that SSIs treatment were 5.5 (4.0 7.7) and 1.6 (1.3 2.0),
are the third most frequently reported nosocomial respectively. 7 Moreover, patients with SSIs re-
infections, accounting for 14 16% of such infections quired longer hospitalisation; the median duration
among hospitalised patients and 38% among sur- of hospitalisation in infected patients was 11 days,
gical patients. 2,4 Similarly, European data suggest compared with 6 days in uninfected patients, and
that the incidence of SSIs may be as high as the median extra duration attributable to SSIs was
20% depending on the procedure, the surveillance 6.5 days (95% CI: 5 8). Similarly, a review of the
criteria used and the quality of data collection. 5 incidence and health economic implications of SSIs
The increasing use of minimally invasive (la- in Europe found that the mean length of extended
paroscopic) surgery has resulted in a decrease in hospitalisation was 9.8 days. 8 As a result, SSIs incur
the incidence of SSIs. For example, in patients considerable increases in healthcare costs. In the
undergoing cholecystectomy, the SSI rate following case control study described above, the median
laparoscopic procedures has been reported to excess cost associated with SSIs during a first
be 1.1%, compared with 4% following open hospitalisation was $3089 (95% CI: $2139 4163),
procedures. 6 Similarly, in patients with acute and this figure increased to $5038 in patients
appendicitis, the SSI rate has been reported to who required readmission. 7 Similarly, European
be 2% with minimally invasive procedures and 8% data suggest that the mean cost of prolonged
with open procedures. 6 Possible reasons for the hospitalisation due to SSIs is €325 per day. 8 Deep
Surgical site infections: epidemiology, microbiology and prevention 5

Table 1
Patient-related and procedure-related factors that may influence the risk of surgical site infections
(adapted from Mangram et al. [2]).

Patient-related Procedure-related

Age Duration of surgical scrub

Nutritional status Skin antisepsis
Diabetes Preoperative shaving
Smoking Preoperative skin preparation
Obesity Duration of operation
Coexistent infection at a remote body site Antimicrobial prophylaxis
Colonisation with micro-organisms Operating room ventilation
(particularly Staphylococcus aureus) Inadequate sterilisation of surgical instruments
Altered immune response Foreign material in the surgical site
Length of preoperative hospital stay Surgical drains
Surgical technique
poor haemostasis
failure to obliterate dead space
tissue trauma

SSIs involving organs or body spaces are associated The risk of SSI in an individual patient can be
with even longer prolongations of hospitalisation, estimated using various scoring systems, such as
and further increases in costs, compared with SSIs the NNIS SSI Risk Index. 2 This index has a range of
that affect only the incision. 2,9 0 3, and is calculated by assigning one point for
Cost estimations from the literature include: each of three variables:
Whitehouse et al. 10 : orthopaedic, 59 matched Duration of surgery longer than the approximate
pairs: Median total direct cost of hospitalizations 75th percentile of the duration of the specific
per infected patient was $24,344, compared with operation being performed.
$6,636 per uninfected patient (P = 0.0001). The presence of a contaminated, or dirty or
Hollenbeak et al. 11 : cardiothoracic (US) (CABG infected, wound.
and valve surgery), 41 matched pairs: Mean A score of >2 (i.e. mild systemic disease) on
additional cost per SSI = $14,000 20,000. the American Society of Anesthesiologists (ASA)
Hebert et al. 12 : clinical orthopaedic: Reimburse- Physical Status Classification.
ment received resulted in an estimated net
loss of approximately $15,000 per case to Microbiology of SSIs
the hospital for the group as a whole, but
approximately $30,000 per case per Medicare In most SSIs, the responsible pathogens origi-
patient. nate from the patient’s endogenous flora. 2 The
most commonly isolated organisms are S. au-
reus, coagulase-negative staphylococci, Entero-
Risk factors for SSIs
coccus spp. and Escherichia coli; however, the
A number of patient-related and procedure-related pathogens isolated depend on the procedure
factors have been shown in univariate or multivari- (Table 2). An increasing number of SSIs are
ate analyses to influence the risk of SSIs (Table 1). attributable to antibiotic-resistant pathogens such
Potential patient-related factors include older age, as meticillin-resistant S. aureus (MRSA) or Candida
pre-existing infection, colonisation with Staphy- albicans. This development may reflect the increas-
lococcus aureus and other potential pathogens, ing number of severely ill or immunocompromised
diabetes and smoking. 2 Procedure-related factors surgical patients, and the widespread use of
include poor surgical technique, the duration of broad-spectrum antibiotics. 2 Pathogens may also
the operation, the quality of preoperative skin originate from preoperative infections at sites
preparation and inadequate sterilisation of surgical remote from the operative site, particularly in
instruments. 2 A recent analysis has identified age patients undergoing insertion of a prosthesis or
and low serum albumin concentrations as the most other implant. 2
important patient-related factors, and the quality In addition to the patient’s endogenous flora, SSI
of surgical technique as an important procedure- pathogens may originate from exogenous sources
related factor; this analysis has also concluded such as members of the surgical team, the
that most SSIs are attributable to patient-related operating theatre environment, and instruments
factors rather than procedure-related factors. 13 and materials brought within the sterile field during
6 C.D. Owens, K. Stoessel

Table 2
Pathogens commonly associated with different surgical procedures (adapted from Mangram et al. 2 )

Type of surgery Common pathogens a

Placement of graft, prosthesis or implant Staphylococcus aureus; CoNS

Cardiac S. aureus; CoNS
Neurosurgery S. aureus; CoNS
Breast S. aureus; CoNS
Ophthalmic S. aureus; CoNS; streptococci; Gram-negative bacilli
Orthopaedic S. aureus; CoNS; Gram-negative bacilli
Non-cardiothoracic S. aureus; CoNS; Streptococcus pneumoniae; Gram-negative bacilli
Vascular S. aureus; CoNS
Appendectomy Gram-negative bacilli; anaerobes
Biliary tract Gram-negative bacilli; anaerobes
Colorectal Gram-negative bacilli; anaerobes
Gastroduodenal Gram-negative bacilli; streptococci; oropharyngeal anaerobes (e.g.
peptostreptococci)
Head and neck S. aureus; streptococci; oropharyngeal anaerobes (e.g. peptostreptococci)
Obstetric and gynaecological Gram-negative bacilli; enterococci; Group B streptococci; anaerobes
Urological Gram-negative bacilli
a
CoNS, coagulase-negative staphylococci.

the procedure. Such pathogens are predominantly with attention to multiple patient-related and
aerobes, particularly Gram-positive organisms such procedure-related risk factors. Several studies in
as staphylococci and streptococci. 2 a variety of clinical settings have shown that such
The risk of an SSI developing after microbial approaches can produce significant reductions in
contamination of the surgical site will depend SSI rates during follow-up periods of up to two
on the dose and virulence of the pathogen and years. 16 22
the patient’s level of resistance, according to the Evidence-based guidelines for the prevention
relationship of SSIs have been published by the CDC. 2 The
Risk of SSI = development of such guidelines is complicated
by the heterogeneous nature of SSIs, which
Dose of bacterial contamination × virulence
. makes it difficult to generalise findings from
Resistance of patient a study in a specific patient population (e.g.
The risk of SSI is considered elevated when the orthopaedic surgery patients) to a wider setting,
level of contamination exceeds 105 organisms per and by the fact that the impact of many routine
gram of tissue, 14 although lower doses may be practices (e.g. wearing surgical gloves) cannot be
required if foreign material such as sutures is evaluated for ethical or logistic reasons. 2 The
present. 2 The virulence of the organism relates principal recommendations of the CDC guidelines
to its ability to produce toxins or other factors are summarised in Table 3.
that increase its ability to invade or damage
tissue. Mortality rates in patients infected with
highly virulent pathogens such as MRSA may be Preoperative strategies
as high as 74%. 15 Preoperative strategies focus on controlling patient-
related risk factors and appropriate hand/forearm
antisepsis for surgical team members (Table 3).
Strategies for SSI prevention
Pre-existing infections at sites remote from the
Strategies for the prevention of SSIs are based both operation site should be identified and treated,
on reducing the risk of bacterial contamination and if practicable elective surgery should be
and on improving the patient’s defences against delayed until such infections have resolved. Obese
infection. This requires a ‘bundle’ approach, patients should be encouraged to lose weight
Surgical site infections: epidemiology, microbiology and prevention 7

Table 3
Principal (category 1) recommendations of the Centers for Disease Control and Prevention (CDC) guidelines for surgical
site infection (SSI) prevention (adapted from Mangram et al. 2 )

Preoperative
Preparation of the patient
(1) Where possible, identify and treat remote infections, and postpone surgery until such infections have resolved (1A)
(2) Do not remove hair around the operation site, unless it will interfere with the operation (1A)
(3) If hair is removed, this should be done immediately before the operation, preferably with clippers (1A)
(4) Adequately control blood glucose in diabetic patients, and avoid perioperative hyperglycaemia (1B)
(5) Encourage tobacco cessation (1B)
(6) Do not withhold necessary blood products as a means of preventing SSIs (1B)
(7) Require patients to shower or bathe with an antiseptic agent on at least the night before the operation (1B)
(8) Thoroughly wash and clean around the incision site to remove gross contamination before performing antiseptic skin
preparation (1B)
(9) Use an appropriate antiseptic for skin preparation (1B)
Hand/forearm antisepsis for surgical team members
(1) Keep nails short and do not wear artificial nails (1B)
(2) Perform preoperative surgical scrub for at least 2 5 min using an appropriate antiseptic. Scrub hands and forearms
up to the elbows (1B)
(3) After performing the surgical scrub, keep hands up and away from the body (elbows flexed). Dry hands with a sterile
towel and don sterile gown and gloves (1B)
Management of infected or colonised surgical personnel
(1) Educate and encourage surgical personnel who have signs and symptoms of transmissible infectious illness to report
conditions promptly to their supervisors and occupation health service (1B)
(2) Develop well-defined policies concerning patient care responsibilities when personnel have potentially transmissible
infectious conditions (1B)
(3) Obtain appropriate cultures from, and exclude from duty, surgical personnel with draining skin lesions until infection
has been ruled out or resolved (1B)
(4) Do not routinely exclude personnel who are colonised with organisms such as S. aureus or Group A streptococci unless
such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting (1B)
Antimicrobial prophylaxis
(1) Administer antimicrobial prophylaxis only when indicated and select agent according to efficacy against most common
pathogens associated with a specific procedure (1A)
(2) Administer initial dose intravenously, timed so that bactericidal concentrations are established in serum and tissues
when incision is made. Maintain therapeutic concentrations in serum and tissue throughout the procedure until at
most a few hours after wound closure in the operating theatre (1A)
(3) Before elective colorectal operations, mechanically prepare the colon by use of enemas and cathartic agents.
Administer non-absorbable oral antimicrobial agents in divided doses on the day before the operation (1A)
(4) For high-risk caesarean section, administer prophylaxis immediately after the umbilical cord is clamped (1A)
(5) Do not routinely use vancomycin for antimicrobial prophylaxis (1B)
Intraoperative
Ventilation
(1) Maintain positive pressure in the operating theatre with respect to corridors and adjacent areas (1B)
(2) Maintain at least 15 air changes per hour, of which three should be fresh air (1B)
(3) Filter all air, recirculated and fresh, through appropriate filters (1B)
(4) Introduce all air at the ceiling, and exhaust near the floor (1B)
(5) Do not use UV radiation in the operating theatre to prevent SSI (1B)
(6) Keep operating theatre doors closed except as needed for passage of equipment, personnel, and the patient (1B)
Cleaning and disinfection of environmental surfaces
(1) When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an
operation, clean affected areas with disinfectant before the next operation (1B)
(2) Do not perform special cleaning or closing of operating theatres after contaminated or dirty operations (1B)
(3) Do not use tacky mats at the entrance to the operating suite or theatre for infection control (1B)
Microbiological sampling
(1) Do not perform routine environmental sampling of the operating theatre. Perform microbiological sampling of
operating theatre environmental surfaces or air only as part of an epidemiological investigation (1B)
Sterilisation of surgical instruments
(1) Sterilise all surgical instruments according to published guidelines (1B)
continued on next page
8 C.D. Owens, K. Stoessel

Table 3, continued
(2) Perform flash sterilisation only for patient care instruments that will be used immediately (e.g. to reprocess a
dropped instrument). Do not use flash sterilisation for reasons of convenience, as an alternative to purchasing
additional instrument sets, or to save time (1B)
Surgical attire and drapes
(1) Wear a surgical mask that fully covers the mouth and nose when entering the operating theatre if an operation
is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the
operation (1B)
(2) Wear a cap or hood to cover fully the hair on the head and face when entering the operating theatre (1B)
(3) Do not wear shoe covers for the prevention of SSI (1B)
(4) Wear sterile gloves if a surgical team member. Put on gloves after donning surgical gown (1B)
(5) Use surgical gowns and drapes that are effective barriers when wet (i.e. materials that resist liquid penetration) (1B)
(6) Change scrub suits that are visibly soiled, contaminated and/or penetrated by blood or other potentially infectious
materials (1B)
Asepsis and surgical technique
(1) Adhere to principles of asepsis when placing intravascular devices or when administering intravenous drugs (1A)
(2) Handle tissue gently, maintain effective haemostasis, minimise devitalised tissue and foreign bodies (e.g. sutures,
charred tissue, necrotic debris), and eradicate dead space at the surgical site (1B)
(3) Use delayed primary skin closure or leave incision open to heal by second intention if the surgical site is considered
to be heavily contaminated (1B)
(4) If drainage is necessary, use a closed suction drain. Place drain through a separate incision distant from the operative
incision. Remove drain as soon as possible (1B)
Postoperative incision care
(1) Protect an incision that has been closed primarily with a sterile dressing for 24 48 h postoperatively (1B)
(2) Wash hands before and after changing dressings and any contact with the surgical site (1B)
Surveillance
(1) Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients (1B)
(2) For inpatient case-finding (including readmissions), use direct prospective observation, indirect prospective
detection, or a combination of direct and indirect methods for the duration of hospitalisation (1B)
(3) For outpatient case-finding, use a method that accommodates available resources and data needs (1B)
(4) For each patient undergoing an operation chosen for surveillance, record those variables shown to be associated
with increased SSI risk (e.g. surgical wound class, duration of operation, etc.) (1B)
(5) Periodically calculate operation-specific SSI rates stratified by variables shown to be associated with increased SSI
risk (e.g. NNIS risk index) (1B)
(6) Report appropriately stratified, operation-specific, SSI rates to surgical team members. The optimum frequency and
format for comparisons of SSI rates will be determined by stratified case-load rates and the objectives of local
continuous quality improvement initiatives (1B)
Category 1 recommendations are ‘strongly recommended for implementation’, and are supported by well designed
clinical, or epidemiological studies; category 1A and 1B recommendations differ only in the strength of the supporting
evidence.

before surgical operations and smokers should approach is not to sterilise tissue, but to reduce
be encouraged to stop smoking (although such intraoperative contamination to levels where it
lifestyle modifications may be unrealistic for many does not overwhelm the patient’s defences. 2
patients). On the night before the operation, the Antimicrobial prophylaxis is primarily indicated
patient can wash or shower with an antiseptic in elective procedures in which skin incisions
agent, and immediately before the operation are closed in the operating theatre. The choice
the skin should be adequately cleaned with an of agent should be based on the pathogens
antiseptic solution. However, hair removal should most commonly associated with the procedure
be avoided unless it is likely to interfere with the being performed (see Table 2). In practice,
operation. If hair removal is necessary, clippers broad-spectrum beta-lactam agents (particularly
should be used rather than shaving, since there cephalosporins) are most widely used, with an
is evidence that shaving can result in microscopic agent such as metronidazole being added if
skin cuts that can act as foci for subsequent necessary to provide cover against anaerobes;
colonisation and infection. 2,23 vancomycin is not recommended for routine
Short courses of antimicrobial prophylaxis are prophylaxis (Table 3). The first dose should be
widely used to reduce SSI risk. The aim of this timed to ensure that bactericidal concentrations
Surgical site infections: epidemiology, microbiology and prevention 9

are achieved in serum and tissue at the time of components of strategies to reduce SSI risk. 2,25
the incision, and these concentrations should then The CDC guidelines recommend that both direct
be maintained for up to a few hours after wound (based on observation of the surgical site by
closure in the operating theatre. appropriate medical personnel) and indirect (based
Surgical personnel should undertake a thorough on retrospective review of patients’ records and
surgical scrub before donning surgical gowns and discussions with clinical staff) methods should be
gloves. Personnel who are colonised or infected used to document the incidence of SSIs associated
with potential pathogens should be encouraged with specific procedures and that these data should
to report their condition, and procedures devel- be reported back to the surgical team.
oped to prevent transmission of pathogens from
colonised personnel to the patient.
Conclusion
Perioperative strategies
SSIs impose a substantial burden of mortality
The CDC guidelines emphasise the importance and morbidity, which in turn imposes heavy
of good surgical technique and aseptic precau- demands on healthcare resources due to prolonged
tions for the prevention of SSIs. Good surgical hospitalisations. Furthermore, in addition to the
technique requires attention to the maintenance increased healthcare costs associated with SSIs,
of haemostasis, removal of devitalised tissue there are indirect costs resulting from lost
and foreign bodies as completely as possible, productivity on the part of the patients and
and elimination of dead space at the surgical their families. SSIs therefore continue to pose an
site. Gloves, facemasks, caps, gowns and sterile important clinical challenge.
drapes should be used to minimise transmission It is important to recognise that much of this
of potential pathogens to the wound. Surgical burden of morbidity and mortality associated
instruments should be adequately sterilised ac- with SSIs is preventable. There is good evidence
cording to published guidelines; flash sterilisation that attention to multiple patient-related and
should be reserved only for instruments intended procedure-related risk factors leads to a decrease
for immediate use (for example, an instrument in SSI risk in diverse clinical settings. In addition,
that has been inadvertently dropped during the emerging technologies such as microbial sealants
operation). offer the potential for assisting in the mobilisation
It should be noted that despite precautions of skin flora which may assist in further reductions
such as these, some contamination of the surgical in infection rates and hence savings in the
site is inevitable because some endogenous healthcare costs associated with SSIs. There is a
bacteria remain even after excellent preoperative
strong case for evaluating such technologies, and
preparation of the site. 24 The use of emerging
for considering implementing them into routine
technologies such as microbial sealants (see the
clinical practice as appropriate.
paper by Wilson in this supplement) therefore
warrants attention in order to reduce the risk of
Funding: None
contamination further.
Conflict of Interest statement: C. Owens and
K. Stoessel are both employed by Kimberly-
Postoperative strategies
Clark Health Care. This employment does not
The risk of SSI can persist for up to 30 days after a create any conflicts of interest regarding this
surgical operation or for as long as one year after an manuscript.
operation in which the patient is given an implant;
indeed, a significant proportion (12 84%) of SSIs are
first detected after the patient has been discharged
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