Surgical-Site-Infections_2021_Infectious-Disease-Clinics-of-North-America

Surgical Site Infections
a,b, a,b
Jessica Seidelman, MD, MPH *, Deverick J. Anderson, MD, MPH
KEYWORDS
Surgical site infection Health care–associated infection Risk Prevention
Outcome
KEY POINTS
Surgical site infections (SSIs) are associated with prolonged hospitalizations, death, and
overall poor patient outcomes.
SSIs are typically caused by pathogens inoculated at the time of surgery from the patient’s
own flora.
SSI acquisition depends on exposure to bacteria and the host’s ability to control the inev-
itable bacterial contamination of the surgical wound.
The 9 core best practices to reduce SSIs address preoperative bathing, antimicrobial pro-
phylaxis, preoperative surgical site preparation, surgical hand preparation, normothermia,
hyperoxygenation, wound protectors, glucose control, and perioperative checklist.
SSI surveillance and feedback decrease SSI rates and are recommended by Centers for
Disease Control and Prevention.
INTRODUCTION
Surgical site infections (SSIs) are a leading cause of health care–associated infections
(HAIs). These infections can range in severity from nuisance to life threatening; overall,
they contribute to substantial patient suffering. A large portion of SSIs are preventable,
and SSI prevention is a key patient safety matter that requires teamwork among mul-
tiple health care personnel, including surgeons, nurses, anesthetists, and infection
preventionists. This article provides updates to the epidemiology and diagnosis of
SSIs with particular emphasis on risk factors, evidence-based prevention strategies,
and surveillance.
a
Division of Infectious Diseases and International Health, Department of Medicine, Duke
University School of Medicine, Duke University, Durham, NC, USA; b Duke Center for Antimi-
crobial Stewardship and Infection Prevention, Duke University Medical Center, Durham,
NC, USA
* Corresponding author. 315 Trent Dr Hanes House, Room 145, Durham, NC 27710.
E-mail address: jessica.seidelman@duke.edu
Infect Dis Clin N Am 35 (2021) 901–929

https://doi.org/10.1016/j.idc.2021.07.006 id.theclinics.com
0891-5520/21/ª 2021 Elsevier Inc. All rights reserved.
902 Seidelman & Anderson
EPIDEMIOLOGY
SSIs are the most common and most costly HAI in the United States, accounting for
almost a quarter of all HAIs.1,2 Although the risk of SSI is generally low, SSIs are com-
mon because of the volume of surgical procedures performed across the United
States. In the United States in 2014, 17.2 million hospital visits (ambulatory or inpa-
tient) included invasive, therapeutic surgeries.3 SSIs occur in 1% to 5% of patients un-
dergoing inpatient surgery.4,5 Rates are generally lower among procedures performed
in outpatient settings. Overall, approximately 300,000 SSIs occur each year, although
this estimate likely underrepresents the true SSI burden because of limitations in sur-
veillance and diagnosis.4,5 SSIs are even more common in low-income and middle-
income countries, occurring in 1% to 24% of procedures performed.6
Overall, rates of SSI are decreasing in the United States. Among 148 hospitals
participating in serial point prevalence surveys performed by the Centers for Disease
Control and Prevention (CDC), the rate of SSI decreased from 0.97 per 100 proced-
ures in 2011 (n 5 11,282 patients reviewed) to 0.56 per 100 procedures in 2015
(n 5 12,299 patients reviewed; P 5 .001).7 Similarly, the publicly reported rates of
SSI following abdominal hysterectomy and colon surgery decreased approximately
10% in 2017 compared with the national baseline reported in 2016, although the de-
creases were not statistically significant.8 However, decreases in SSI have been
modest compared with decreases observed in several other HAIs, including central
line–associated bloodstream infection, catheter-associated urinary tract infection,
methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and Clostridioides
difficile infection.
Rates of SSI vary by type of procedure and by setting. The CDC’s National
Healthcare Safety Network (NHSN) no longer routinely reports national rates of
SSI following commonly performed procedures; therefore, most nationwide esti-
mates currently used are from data reported almost 10 years ago. Clean-
contaminated and dirty procedures, including procedures that enter a nonsterile
viscera, have higher rates of SSI than clean procedures. For example, rates of
SSI following colon, rectal, or other gastrointestinal (GI) procedures range from
4% to 25%, whereas the rate of SSI following coronary artery bypass grafting is
approximately 3% and following hip or knee arthroplasty is 1% or lower.9 In
most cases, rates of SSI at surgical centers are inversely associated with surgical
volume. That is, the more procedures performed, the lower the rate of SSI.8
Although referral centers typically care for more complex patients and perform
higher-risk procedures, these risks are often offset by high surgical volume and
experience. Small community hospitals with low volume have higher rates of SSI
than higher-volume community hospitals.10
CLINICAL OUTCOMES
SSIs lead to significant patient morbidity and mortality. Each SSI is associated with
approximately 7 to 11 additional postoperative hospital days.2,11 In total, patients
with SSIs have 3.7 million excess hospital days each year.12 Surgical patients who
develop an SSI have a risk of death that is, between 2-fold and 11-fold higher than pa-
tients without an SSI13; 77% of deaths in patients with SSI are directly attributable to
SSI.14 Investigators from the Agency for Healthcare Research and Quality (AHRQ) esti-
mated excess mortality related to SSI was 0.026 (95% confidence interval [CI], 0.009–
0.059, meaning 26 deaths occur for every 1000 SSIs).15 Each SSI leads to approxi-
mately $25,000 of additional costs, although attributable costs of SSI vary depending
on the type of operative procedure and the type of infecting pathogen.11,13,15 Overall,
Surgical Site Infections 903
SSIs are estimated to account for $3.5 billion to $10 billion annually in United States
health care expenditures using the CPI (consumer price index for inpatient hospital
services with all cost estimates adjusted for 2007 dollars).5
EVALUATION
Clinically, a surgical wound is considered infected when purulent drainage is present

at the incision site or there is evidence of abscess involving the surgical bed. However,
other presentations of surgical wound infections also occur, including wound dehis-
cence, nonpurulent drainage, local erythema, induration, pain, or systemic signs of
infection. Because of the varied presentation of SSIs, many of which overlap with
noninfectious causes, no single clinical definition of SSI exists. Instead, the diagnosis
of SSI is typically made based on a constellation of clinical and examination features,
laboratory and microbiologic data, and radiography results.
Despite the variability in clinical presentations of SSIs, specific definitions of SSI
are used for epidemiologic and surveillance purposes. The NHSN provides the
most commonly used SSI definitions. These definitions were designed to be objec-
tive and easy to apply but also flexible enough to identify clinically relevant SSIs with
varied presentations.16 NHSN categorizes SSIs into 3 groups: superficial incisional
(involving the skin or subcutaneous tissue layers of the incision), deep incisional
(involving muscle or connective tissue layers of the incision), and organ/space
(involving structures, organs, or spaces deep to the incision) (Fig. 1, Table 1). Exam-
ples of organ/space infection include intra-abdominal abscess following colon sur-
gery, periprosthetic joint infection following joint arthroplasty, and mediastinitis
following cardiac surgery. Per NHSN definitions, surveillance for superficial-
incisional infections is conducted for 30 days, whereas surveillance for deep-
incisional and organ/space infections is conducted for 30 or 90 days, depending
on the index surgical procedure.
Note that surveillance definitions have changed over time and that various epidemi-
ologic surveys and studies of SSI prevention have used variable case-finding methods
(eg, active vs passive surveillance), criteria for inclusion (eg, index procedure vs all
procedures), depth of infection (eg, superficial-incisional, deep-incisional, or organ/
space infection), and surveillance periods (eg, 30 vs 90 days). For example, 10% fewer
SSIs were identified when, compared with previously used NHSN definitions, updated
2013 NHSN definitions that shortened surveillance periods were applied retrospec-
tively to SSI surveillance data from a network of 35 hospitals and 2 ambulatory surgery
centers.17 Therefore, it is important to understand the surveillance criteria used when
interpreting SSI data from different surveys or time periods, and how different criteria
can affect reported rates.
CURRENT EVIDENCE
SSIs are typically caused by pathogens inoculated at the time of surgery. Most SSIs
are caused by the patients’ endogenous flora. However, exogenous sources of wound
contamination are possible.14,18 Most SSIs are caused by skin pathogens, although
enteric pathogens are frequently seen in SSIs following GI procedures (Table 2).19
Overall, S aureus is the most common cause of SSI. Although MRSA was previously
a more frequent cause of SSI than methicillin-sensitive S aureus (MSSA), rates of
MRSA SSI have declined; MSSA is now a more common cause of SSI than MRSA.9
This trend is important because SSIs caused by resistant pathogens such as MRSA
lead to worse clinical outcomes than SSIs caused by susceptible pathogens.11 Out-
breaks involving atypical organisms such as Mycoplasma, Ureaplasma, Candida
Fig. 1. NHSN categorization of SSIs. (From Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori
TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC defini-
tions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606-608; with
permission)
and other fungi, Nocardia, Rhodococcus, and nontuberculous mycobacteria

(including rapidly growing mycobacteria) are uncommon, but have been
described.20–22
Endogenous Contamination
Most SSIs are caused by the patients’ endogenous flora contaminating the surgical
site.18 Even an inoculum as low as 100 colony-forming units into the wound can
lead to an SSI.23 Several factors may modify the risk of surgical wound contamination
by endogenous flora.
Perioperative antibiotics
The absence of antibiotic prophylaxis also significantly increases the risk of SSI.24
Contamination of operative sites, even clean ones, is unavoidable despite the best
preparation and operative technique. The goal of antimicrobial prophylaxis is to
reduce the risk of SSI by reducing the burden of microorganisms at the surgical site
during the operative procedure.
Skin antisepsis
In addition, lack or inappropriate application of preoperative skin antiseptics increases
the risk of SSI by failing to remove transient organisms from the skin where a surgical
incision will be made. Effectiveness of incisional site preparation depends on correct
application. Although skin disinfection before surgery drastically reduces the number
Table 1
Summary of National Healthcare Safety Network surveillance criteria for surgical site infection
based on 2021 definitions
Superficial Incisional Deep Incisional Organ/Space

Any of the following: Any of the following: Any of the following:
Purulent drainage Purulent drainage from Purulent drainage from a
Organism identified from the deep incision drain that is placed into
aseptically obtained A deep incision that the organ/space
specimen or superficial spontaneously dehisces Organism identified from
incision deliberately or is deliberately opened fluid or tissue in the
opened by surgeon, or aspirated by a organ/space
attending physician, or surgeon, attending Abscess or other evidence
designee physician, or designee, of infection involving the
Diagnosis of superficial and organism identified organ/space that is
incisional SSI by surgeon, from deep soft tissues of detected on gross
attending physician, or the incision and 1 or anatomic or
other designee culture more of the following histopathologic
not obtained symptoms: fever >38 C, examination, or imaging
localized pain or test evidence suggestive
tenderness of infection
Abscess or other evidence
of infection involving the
deep incision that is
detected on gross
anatomic or
histopathologic
examination, or imaging
test
Deep incisional involves part of the incision deeper than the fascial layer. Organ/space involves any
part of the body that is deeper than the muscle/fascial layers and was manipulated or entered dur-
ing the operative procedure.
Modified from Centers for Disease Control and Prevention. Surgical Site Infection (SSI) Event
Web site. https://www.cdc.gove/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Accessed 11/20/20.
of bacteria on the skin’s surface, recolonization of the skin with bacteria from deeper
skin layers and hair follicles may occur during the operation.25
Preoperative hair removal

Preoperative shaving of the surgical site is associated with a significantly higher SSI
risk than either the use of depilatory agents or no hair removal.14 One study found
that SSI rates for patients who shaved before surgery was 5.6% compared with an
SSI rate of 0.6% in patients who removed hair via depilatory agent or did not remove
hair at all. The increased risk of SSI with shaving is attributed to microscopic cuts in the
skin that later serve as niduses for bacteria to multiply. In addition, timing of hair
removal is a key factor for development of SSI. One study found that patients who
shaved immediately before the operation compared with patients who shaved within
24 hours preoperatively had lower rates of SSI (3.1% vs 7.1%).26 Furthermore, if pa-
tients shaved more than 24 hours before operation, their SSI rates exceeded 20%.26
Similarly, clipping hair immediately before an operation is associated with a lower risk
of SSI than shaving or clipping the night before surgery (1.8% vs 4.0%).27 Depilatory
agents are associated with lower SSI risk compared with shaving or clipping26; how-
ever, these products can produce hypersensitivity reactions, which can compromise
the integrity of the skin.26
Table 2
Common causes of surgical site infections
Clean Cardiac Bypass

and Joint Arthoplasties81,a Community Hospitals9,b
N 5 6263 N 5 3988 SSIs
Organism n (%); Rank n (%); Rank
S aureus 2704 (41); 1 1357 (34); 1
MSSA 1520 (23) 683 (17)
MRSA 1184 (18) 674 (17)
Coagulase-negative staphylococci 1085 (17); 2 340 (9); 4
Enterococcus species 433 (7); 3 467 (12); 3
Pseudomonas aeruginosa 339 (5); 4 168 (4); 7
Escherichia coli 314 (5); 5 482 (12); 2
Streptococcus species 278 (4); 6 242 (6); 5
Abbreviation: MSSA, methicillin-sensitive S aureus.

a
6263 complex SSIs identified after 680,489 procedures performed in 880 hospitals over a 4-year
period.
b
3,988 complex SSIs identified after 532,694 procedures performed in 29 community hospitals
over a 5-year period.
Exogenous Contamination
Length of operation
Prolonged operative time may increase the risk of SSI. The increased risk may be
related to increased wound contamination, increased tissue damage (eg, bleeding,
cautery, suture), or some combination of these factors.28
Surgical technique
Poor surgical technique is widely thought to increase SSI risk.14 Examples of poor sur-
gical technique that may increase subsequent SSI risk include failure to maintain
adequate blood supply, rough manipulation of tissues, accidental entry into a hollow
viscus, leaving behind devitalized tissue, and inappropriate use of drains and sutures.
In general, the impact of poor surgical technique is difficult to quantify or study.
Foreign material
Any foreign material, such as sutures or drains, promotes inflammation at the surgical
site and increases the risk of SSI.29 Furthermore, the presence of foreign material de-
creases the inoculum required to cause an SSI from 106 to 102 organisms.30
Wound contamination from operating room personnel

Health care personnel’s hands and fingernails harbor bacteria that may be introduced
into the surgical site.31 Application of surgical gloves substantially reduces but does
not prevent the potential passage of microorganisms to the patient. Gloves can
become perforated during surgery and bacteria on gloved hands can multiply rapidly.
Therefore, absence of appropriate hand antisepsis can expose patients to potential
pathogens harbored on operating room personnel’s hands. Furthermore, watches,
long finger nails, artificial nails, and finger rings can increase bacterial counts on the
hands of operating room personnel.32,33 The number of SSIs caused by exogenous
flora is unknown, although several outbreaks of SSI have been attributed to operating
room personnel.
Airborne contamination
Transmission of bacteria from operating room personnel to patients can occur through
several other routes, including shedding of bacteria from the personnel’s hair, skin,
and clothing. Actions that increase bacterial air counts are strongly associated with
SSI risk.34 Most of the airborne contamination comes from persons present in the
operating room and their movements.35 Several studies investigated the impact of
operating room door openings on air quality, and the results were mixed.36 However,
some data suggest a positive correlation between high door opening rates and
numbers of microorganisms in air samples.37
Wound care
Postoperative wound care practices are thought to modify risk of SSI.38 Wounds that
remain uncovered after surgery may be subject to environmental contamination or
ongoing drainage that decreases the integrity of the surrounding skin.39
Intra-articular steroid injections

The relationship between intra-articular steroid injections and incidence of SSIs is under
ongoing investigation. Infection may be introduced at the time of injection, especially if
rigorous antisepsis is not applied.40 In addition, the intra-articular steroid may decrease
the host immune response to the introduction of such bacteria. Although some studies
have shown an increase in SSI incidence in patients who receive intra-articular steroid
injections,41 other trials show no difference in SSI risk between patients who receive
intra-articular steroid injections and those who do not.42 Current clinical guidelines
from the American Academy of Orthopedic Surgeons (AAOS) do not outline specific
recommendations for intra-articular injection administration and SSI prevention.43
Periarticular injections
Recently, surgeons have incorporated local analgesia into pain management regi-
mens for patients undergoing joint replacement surgery in order to improve postoper-
ative pain control and promote early activity.44 Physicians inject a wide variety of
medications and often prepare them without the use of a sterile hood. Infection can
be introduced when these injections are compounded or at the time of injection.
Although no definitive evidence shows an increased risk of SSI associated with use
of periarticular injections, medication cocktails should be compounded in a sterile
fashion in the pharmacy and be administered with aseptic technique.45
Risk Factors
SSI acquisition depends on exposure to bacteria and the host’s ability to control the
inevitable bacterial contamination of a surgical wound. The likelihood of developing an
SSI is a complex interaction among several variables, including overall host character-
istics (ie, age, immunosuppression, obesity, diabetes), effectiveness of antimicrobial
prophylaxis, surgical site tissue condition and presence of foreign material, and de-
gree of wound contamination.
Table 3 provides a summary of known SSI risk factors, which are also discussed in
detail later. Some risk factors that increase risk of SSI are nonmodifiable, such as
gender and age. However, other risk factors are modifiable, and their optimization
can decrease the likelihood of developing an SSI.
Patient Related, Nonmodifiable

Age
Several studies identify the extremes of age as a risk factor for SSI. The risk of SSI is
higher in infants compared with older children and higher among older adults compared
Table 3
Summary of known surgical site infection risk factors
Risk Factor Pathophysiology

Patient Related, Modifiable
Diabetes Hyperglycemia impairs innate immunity
mechanism to fight bacteria. In addition,
increased glucose level leads to
glycosylation of proteins, which in turn
slows wound healing52
Malnutrition Poor nutrition leads to poor tissue healing,
decreased collagen synthesis, and
granuloma formation in surgical wounds.
Low albumin level impairs macrophage
activation and induces macrophage
apoptosis, which decreases innate
immunity response. Hypoalbuminemia can
lead to tissue edema and leakage of
interstitial fluid into the surgical wound57
Smoking tobacco Tobacco smoke impairs wound healing by
vasoconstriction, leading to relative
ischemia, reduced inflammatory response,
and alteration in collagen metabolism61
Obesity Decreased blood flow in adipose tissue leads
to less oxygen and antibiotic
delivery64,66,67
Immunosuppressive medications and Immunosuppressive medications or clinical
conditions conditions blunt the inflammatory phase
of wound healing68,69
Decreased tissue oxygenation Decreased tissue oxygenation leads to
diminished oxidative killing by neutrophils
and impaired tissue healing caused by
reduced collagen formation,
neovascularization, and epithelialization.
Low oxygen levels may decrease the
efficacy of perioperative antibiotics72,73
Perioperative hypothermia Perioperative hypothermia impairs host
defenses against surgical wound
contamination: vasoconstriction causing
reduced tissue perfusion to wounded
tissue with reduced access for key immune
cells, decreased motility of key immune
cells, and reduced scar formation74
Postoperative hyperglycemia Cellular functions of leukocyte adherence,
chemotaxis, phagocytosis, and bactericidal
activity are improved by insulin and better
glycemic control, suggesting a direct
relation between cellular function deficits
and increased blood glucose level56
Anticoagulation Anticoagulants can cause of persistent
oozing of the incision, slow wound
healing75
Blood transfusions Blood transfusions affect the risk of infection
by modulating the immune system76
(continued on next page)

Table 3
(continued )
Patient Related, Nonmodifiable
Age The skin’s dermis and basement membrane
thin with increasing age, and the skin loses
its supply of cutaneous nerves and blood
vessels, which can lead to poor wound
healing46
History of radiation Radiation therapy produces underlying
tissue damage and contributes to poor
wound healing
History of prior SSTI A prior history of SSTIs may be related to
differences in inherent immunity and
susceptibility to infection51
Exogenous Sources
Wound contamination from operating Transition of skin flora on the hands of
room personnel health care personnel to the patient and
operating room from lack of appropriate
hand washing or gloving to surgical sites23
Movement of microorganisms from surgical
staff’s hair, mouths, bodies, or shoes to the
operating room contaminates surgical
wounds23
Airborne contamination Increasing the number of microorganisms in
the operating room environment increases
opportunity for SSI. Most of the airborne
contamination comes from persons
present in the operating room and their
movements34,35
Operation duration Longer operative duration is associated with
increased wound contamination,
increased damage to wound cells, and the
local environment28
Surgical technique Not maintaining adequate blood supply, not
gently handling tissue, inadvertent entry
into hollo viscus, leaving behind
devitalized tissue, inappropriate use of
drains and sutures, and inappropriate
postoperative wound management14
Foreign material Foreign material promotes inflammation at
the surgical site and increases the risk of
SSI29,30
Intra-articular steroid injection Infection may be introduced at the time of
injection, especially if rigorous antisepsis is
not applied. May decrease the host
immune response to the introduction of
such bacteria81
Periarticular joint injections Injections are often prepared without the
use of a sterile hood; infections can be
introduced when these injections are
compounded or at the time of infusion,

Table 3
(continued )
because catheters are commonly used to
deliver the medications45
Wound care Wounds that remain uncovered after surgery
may be subject to environmental
contamination or ongoing drainage that
decreases the integrity of the surrounding
skin38,39
Endogenous Sources
Wound contamination from patient Shaving creates microscopic cuts in the skin
that later serve as niduses for bacteria to
multiply14
Absence of appropriate barrier devices and
drapes allows bacteria from deeper skin
layers and hair follicles to recolonize the
surgical site during the operation
Lack of or inappropriate administration of
perioperative antibiotics does not prevent
the inevitable burden of microorganisms
at surgical site24
Without appropriate surgical site
preparation, soil and transient organisms
are not removed117
Wound classification delineates the degree
of contamination of a surgical wound at
the time of the operation118
with younger cohorts.46 With increasing age, the skin’s dermis and basement mem-
brane thins. In addition, the skin loses its supply of cutaneous nerves and blood vessels.
These physiologic changes contribute to slow or impaired wound healing.47,48
However, the risk of SSI may only increase up until a certain age. Kaye and col-
leagues49 found that, after age 65 years, the risk of SSI decreased by 1.2% for
each additional year of life. Therefore, the risk of SSI may be caused by comorbidities
and immunosuppression and not directly by increasing age. Furthermore, this result
may indicate a selection bias of healthier older patients for surgery.
History of radiation
History of prior radiation therapy at the site of surgery increases SSI risk because of the
risk of underlying tissue damage.50 Irradiated skin is hypovascular and easily injured with
slight trauma. Given the damaged tissue and lack of perfusion, surgical incisions in loca-
tions with prior radiation treatment are more likely to develop a wound complication.
History of prior skin and soft tissue infection

History of a prior skin and soft tissue infection (SSTI) is another risk factor for SSI
development.51 Although not fully understood, the increased SSI risk among these pa-
tients may reflect differences in inherent immunity and susceptibility to infection.
Patient Related, Modifiable

Diabetes mellitus
Patients with diabetes mellitus are more likely to develop SSIs. In a meta-analysis
including 14 prospective studies, patients diagnosed with diabetes were twice as
likely to develop an SSI compared with patients without a diagnosis of diabetes.52 The
increased risk of SSI among patients with diabetes is consistent across multiple sur-
gical procedures and is likely multifactorial.53 Patients with diabetes have a high inci-
dence of small vessel disease, leading to impaired oxygen and nutrition delivery to
peripheral tissues. Hypoxemia and lack of nutritional support reduce the systemic
ability to prevent infection.54 Dronge and colleagues55 found that patients with a he-
moglobin A1c level more than 7% were significantly more likely to develop infectious
complications compared with patients with a hemoglobin A1c level less than 7%.
Postoperative hyperglycemia
Postoperative hyperglycemia may increase SSI risk more than a diagnosis of diabetes.
Hyperglycemia impairs innate immunity mechanism to fight bacteria. In addition,
increased glucose level leads to glycosylation of proteins, which in turn slows wound
healing. Latham and colleagues56 found that hyperglycemia during the immediate
postoperative period was an independent risk factor for developing SSI even among
patients without a history of diabetes, and the risk of infection correlated with the de-
gree of glucose increase. Patients with blood glucose level of 200 mg/dL or higher
within 48 hours after surgery had 2.5 times higher odds of developing an SSI than pa-
tients with glucose level less than 200 mg/dL.
Malnutrition
Malnutrition is prevalent among surgical patients. One of the most commonly used
markers of malnutrition is albumin, and hypoalbuminemia increases the risk of
SSI.57 Hypoalbuminemia may lead to increased risk of SSI through several mecha-
nisms. First, hypoalbuminemia can lead to poor tissue healing, decreased collagen
synthesis, and granuloma formation in surgical wounds.58 These factors can impair
wound healing and predispose the tissue to infection. Second, low albumin level im-
pairs macrophage activation and induces macrophage apoptosis, which decreases
innate immunity response.59 Lastly, hypoalbuminemia can lead to tissue edema and
leakage of interstitial fluid into the surgical wound.60 This fluid can serve as a medium
for bacteria to proliferate and ultimately lead to infection.
Smoking
Smoking tobacco is associated with adverse outcomes following surgery, including
SSI. Postoperative wound healing complications occur more often in smokers and
former smokers compared with those who never smoked. A systematic review iden-
tified 4 randomized trials that assessed the effect of preoperative smoking cessation
(4-week to 8-week interval of abstinence) on postoperative wound healing. Current or
past smokers had an increased risk for postoperative infection (odds ratio [OR], 1.9;
CI, 1.0–3.5).61 Other studies have shown that abstinent smokers have a lower SSI
risk than do current smokers.62
The many compounds that constitute tobacco smoke impair wound healing and in-
crease SSI risk through several mechanisms.63 The physiologic mechanisms include
vasoconstriction, which causes relative ischemia of operated tissues. Tobacco smoke
also leads to a reduced inflammatory response and impaired innate immune system
response to bacteria.63 Lastly, the elements in tobacco smoke can alter collagen
metabolism, which is essential for skin and tissue integrity.
Obesity
Obesity is another risk factor associated with developing SSI. One meta-analysis
included 20 studies that evaluated SSI outcomes in orthopedic surgeries. The inves-
tigators found that the risk of SSI for patients with obesity was almost 2 times the SSI
risk for patients without obesity (risk ratio [RR], 1.915; 95% CI, 1.53–2.40).64 Studies
including colorectal surgery patients (OR, 1.59; 95% CI, 1.32–1.91)65 and coronary ar-
tery bypass surgery patients (OR, 1.8; 95% CI, 1.4–2.3)66 have reported similar con-
clusions. An additional recent study also found a trend of increasing risk of SSI for
almost all surgery types when body mass index increased from normal to morbidly
obese.67
Obese patients may be at increased risk for SSI because of depth of adipose tissue,
creation of dead space, and decreased blood flow in adipose tissue. Without
adequate blood flow reaching the tissues, surgical wounds are less likely to heal.
Decreased blood flow may also reduce antibiotic delivery and increase wound
tension.28
Immunosuppressive medications and conditions
Patients with suppressed immune systems are at increased risk of SSI because the
inflammatory phase of wound healing may be blunted. The increase in SSI risk is
seen in patients with various levels of immunosuppression, including transplant recip-
ients, patients undergoing chemotherapy, and other patients taking immunosuppress-
ing medications.68,69 In contrast, glucocorticoids may not affect SSI risk as strongly as
other immunosuppressive therapies.70 Some degree of antiinflammation may prevent
wounds from becoming chronically inflamed, whereas significant suppression of
inflammation can prevent wound healing.71
Decreased tissue oxygenation
Low oxygenation also increases the risk of SSIs. Oxygen tension is often low in wounds
and in colorectal anastomoses at the end of surgery, which may reduce bacterial erad-
ication, the body’s defenses against bacteria, and tissue healing. Possible mechanisms
include diminished oxidative killing by neutrophils and impaired tissue healing caused
by reduced collagen formation, neovascularization, and epithelialization.72 Further,
many of the antibiotics used perioperatively for SSI prophylaxis are oxygen dependent
in their effect,73 and low oxygen levels may decrease their effectiveness.
Perioperative hypothermia
Maintaining normal body temperature is vital for the body to maintain its normal func-
tion. However, many factors that patients are exposed to in the operating room can
cause hypothermia: anesthetic drugs, cold operating room, skin antisepsis, cold irri-
gation of a patient with the body uncovered, and the use of intravenous solutions.
Most cellular functions are temperature dependent, and hypothermia also provokes
systemic responses.74 Several mechanisms help to explain why perioperative hypo-
thermia impairs host defenses against surgical wound contamination, including vaso-
constriction and subsequent diminished perfusion, decreased motility of key immune
cells, and reduced scar formation, which is necessary to prevent wound dehiscence
and recontamination.
Anticoagulation
Although postoperative anticoagulation is an evidence-based practice to prevent
deep vein thrombosis in the postoperative period, anticoagulants may increase the
risk of SSIs. Several studies have implicated anticoagulation therapy as a cause of
persistent oozing of the incision, slow wound healing, and subsequent SSIs.75
Blood transfusions
Red blood cell transfusion also increases the risk of SSI.76 Blood transfusions increase
the risk of infection by impairing normal monocyte function and decreasing tumor ne-
crosis a production in response to endotoxin (lipopolysaccharide).77
GUIDELINES FOR PREVENTION
Several detailed published guidelines for SSI prevention exist, including the following 4
published primary guideline documents:
1. “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Up-
date.” 78 The Society for Healthcare Epidemiology of America (SHEA) sponsored
this document, and members of numerous other organizations with SSI prevention
expertise also contributed.
2. “Global Guidelines for the Prevention of Surgical Site Infection.”79 The World Health
Organization (WHO) published this updated document in 2018.
3. “American College of Surgeons and Surgical Infection Society: Surgical Site Infec-
tion Guidelines, 2016 Update.”80
4. “Centers for Disease Control and Prevention Guideline for the Prevention of Surgi-
cal Site Infection, 2017.”81
Based on these guideline documents, available evidence, and our personal experi-
ence, the authors have categorized SSI prevention strategies into 3 categories: best
practices that all acute care hospitals should follow, additional interventions with
possible benefit, and unproven or controversial interventions.
Recommendations
The authors have identified 9 core best practices that are consistently recommended
by SSI prevention experts and guideline documents (Table 4). The authors recom-
mend that all acute care hospitals incorporate each of the following SSI prevention
measures into surgical protocols:
Preoperative bathing
Preoperative bathing or showering on the night before or day of surgery is a simple,
low-risk intervention that decreases bacterial load of the skin, including the surgical
site.82 Many experts strongly recommend this practice as a standard of care for SSI
prevention,81 but definitive reduction in SSI risk has not been proved. Furthermore,
for routine preoperative bathing, the ideal soap or antiseptic agent is not known,
and many hospitals implement bathing protocols based on local epidemiology and
cost considerations (preoperative bathing with chlorhexidine gluconate [CHG] is dis-
cussed later).
Antimicrobial prophylaxis
Antimicrobial prophylaxis given shortly before surgical incision is indicated for most
clean-contaminated procedures, as well as certain clean procedures with severe
consequences of infection (eg, procedures involving implantation of prosthetic im-
plants).79 Multispecialty consensus guidelines recommend preferred antibiotic
agents based on common pathogens known to cause SSI following particular pro-
cedures; however, local epidemiology of SSI and hospital antibiograms should
also influence antibiotic selection.83 Antimicrobial prophylaxis protocols should pro-
mote optimized timing and dose of antibiotics, including redosing of antibiotics dur-
ing surgery for prolonged procedures, or when blood loss is excessive. For
nonemergent colorectal procedures, oral antibiotics and mechanical bowel prepara-
tion should be provided on the day before surgery, in addition to intravenous anti-
biotic prophylaxis before skin incision.78–80 Prophylactic antibiotics should be
discontinued after closure of incision because of increased risk of adverse events
and because no SSI reduction benefit associated with postoperative antibiotic pro-
phylaxis has been shown.79,81
Table 4
Summary of surgical site infection primary prevention guidelines, risk factors, and best-
practice recommendations
Recommendations and
Prevention Guideline Risk Factor Addressed Supporting Evidence
Preoperative bathing Endogenous bacterial Patients should bathe
contamination of their full bodies with
surgical site soap or an antiseptic
agent on at least the
night before or day of
surgery79,81
Antimicrobial prophylaxis Endogenous and Administer prophylactic
exogenous bacterial antibiotics for indicated
contamination of procedures according to
surgical site evidence-based
guidelines83
Select agent based on
common pathogens that
cause SSI for procedure
being performed,
published guidelines,
and local antibiograms.83
Begin antibiotic infusion
within 60 min before
incision; however, for
vancomycin and
fluoroquinolones, begin
infusion within 120 min
before incision78,80,83
Adhere to guidelines for
antibiotic doses,
including weight-based
vancomycin dosing and
3-g cefazolin doses for
patients with
weight >120 kg.78,83
Redose antibiotics during
surgery for prolonged
procedures or for
procedures with
excessive blood loss78,83
Provide oral antibiotics,
intravenous antibiotics,
and mechanical bowel
preparation before
nonemergent colorectal
procedures78–80
Discontinue
perioperative antibiotics
after closure of surgical
incision79,81
Perioperative preparation Endogenous and Avoid hair removal at
of operative site exogenous bacterial operative site unless hair
contamination of interferes with surgery. If
surgical site hair must be removed,

Table 4
(continued )
Recommendations and
remove hair outside of
operating room with a
clipper or depilatory
agent78,79
Use an alcohol-based
antiseptic solution
containing chlorhexidine
for surgical skin
preparation, unless a
contraindication exists79
Use chlorhexidine or
povidone-iodine
solutions that contain
low concentrations (eg,
4%) or no alcohol for
vaginal antisepsis before
hysterectomy and
vaginal procedures,
including cesarean
section87,88
Surgical hand preparation Exogenous bacterial Use an appropriate
contamination of antiseptic agent to
surgical site perform surgical hand
scrub for the length of
time recommended by
the manufacturer78,79
Maintenance of Hypothermia-induced Use warming devices in
normothermia vasoconstriction and the operating room
tissue hypoxia at surgical before and during the
site surgical procedure to
maintain body
temperature of at least
36.0 C78,79
Hyperoxygenation Tissue hypoxia at surgical For patients undergoing
site general anesthesia and
tracheal intubation and
who have normal
pulmonary function,
provide 80% FiO2
intraoperatively and,
when possible, for 2–6 h
after surgery78,79,81
Wound protectors Endogenous and Use impervious plastic
exogenous bacterial wound protectors for
contamination of open abdominal surgery,
surgical site particularly colorectal
and biliary tract
procedures78,80
Glucose control Hyperglycemia Maintain immediate
postoperative blood

Table 4
(continued )
Recommendations and
glucose of 180 mg/dL
for diabetic and
nondiabetic patients78–80
Perioperative checklist Potential for Use a checklist based on
noncompliance with best the WHO Surgical Safety
practices Checklist90 to improve
compliance with best
practices, including SSI
prevention strategies78
Abbreviation: FiO2, fraction of inspired oxygen.
Perioperative preparation of operative site

Hair removal should be performed only if hair interferes with surgery.78,84 When hair
removal is necessary, a clipper or depilatory agent should be used outside of the oper-
ating room. Hair shaving should not occur. If a clipper is used, a disposable clipper
head should be used and changed between patients.
Surgical skin preparation should be performed with an alcohol-containing antiseptic
solution, unless a contraindication to the alcohol component exists (eg, procedures
involving mucosa, cornea, or ear).78 Alcohol-based skin preparation agents are flam-
mable, and operating room personnel should take precautions to avoid fires in the
operating room, especially for procedures using an electrosurgical device (eg,
Bovie).85 Personnel should allow the skin preparation solution to dry per manufacturer
instructions for use and avoid pooling of the solution.
WHO guidelines preferentially recommend the use of CHG-alcohol solutions rather
than povidone-iodine-alcohol solutions,79 whereas other organizations do not make
specific recommendations regarding type of alcohol-containing solution. Although
few head-to-head studies have been performed to compare efficacy of CHG versus
povidone-iodine–containing solutions, CHG alcohol was superior to povidone-iodine
alcohol in a randomized controlled trial analyzing SSI prevention following cesarean
section.86 As a result, the authors preferentially recommend use of CHG alcohol for
skin antisepsis. Vaginal cleansing with either 4% CHG or povidone-iodine should
occur before hysterectomy and vaginal procedures, including cesarean section.87,88
Surgical hand preparation

Surgical hand preparation should be performed with either a suitable antimicrobial
soap or alcohol-based hand rub.78,79 Hand preparation should occur for the duration
recommended by the manufacturer of the antiseptic agent chosen.
Maintenance of normothermia
Preoperative and intraoperative warming devices should be used in order to maintain
temperature of at least 36.0 C.74,78,84 In addition to decreasing SSI risk, maintenance
of normothermia may also decrease blood loss and transfusion requirements.
Hyperoxygenation
Patients who undergo surgery with general anesthesia and tracheal intubation and
who have normal pulmonary function should receive 80% fraction of inspired oxygen
(FiO2) intraoperatively and, when feasible, for 2 to 6 hours postoperatively.78,79 The
benefit of hyperoxygenation may be greatest for open colorectal surgery. Updated

WHO guidelines continue to recommend hyperoxygenation despite exclusion of 2
studies that showed benefit but have subsequently received scrutiny for possible
data integrity breaches.89
Glucose control
Blood glucose should be monitored and controlled in the immediate postoperative
time period for all surgical patients, including patients with and without a diagnosis
of diabetes mellitus.78–80 Protocols should be used to ensure that postoperative
glucose monitoring occurs and that insulin is used to maintain glucose level less
than or equal to 180 mg/dL for at least the first 24 hours after surgery. At a minimum,
we recommend that all hospitalized postoperative patients without diabetes mellitus
have 1 blood glucose value checked in the first 24 hours after surgery.
Perioperative checklist
Acute care hospitals should use surgical safety checklists to improve compliance with
best practices for SSI prevention.78 The authors recommend that hospitals modify the
19-item WHO Surgical Safety Checklist90 to include additional SSI prevention prac-
tices detailed here, as well as other important SSI prevention measures applicable
to the specific hospital or procedure.
Considerations
Numerous potentially effective SSI prevention strategies are not included in the 9 core
best practices listed earlier. Compared with the core interventions, these additional
strategies do not have the same strength of endorsement by SSI prevention guidelines
or experts and have fewer data to support universal implementation. However, espe-
cially for hospitals, procedures, or patient populations with increased SSI rates
despite adherence to core SSI prevention measures, implementation of additional
strategies may help to decrease SSI risk.78 This article discusses the following 4
commonly used auxiliary strategies for SSI prevention.
Staphylococcus aureus screening and decolonization

Patients undergoing high-risk cardiothoracic, orthopedic, or neurosurgical proced-
ures known to be colonized with S aureus should receive preoperative intranasal
mupirocin 2% ointment or an alternative intranasal agent with antistaphylococcal ac-
tivity, as well as CHG bathing for up to 5 days before surgery.78,84 However, no stan-
dardized approach exists for S aureus screening or decolonization, and guideline
documents give conflicting recommendations regarding the practice of universal
decolonization of patients undergoing high-risk procedures. For example, the WHO
strongly recommends against routine decolonization of patients not known to be S
aureus carriers, primarily to avoid spread of resistance to mupirocin.79
Although optimal strategies for S aureus screening and targeted decolonization
versus universal decolonization before high-risk surgical procedures continue to
be debated, experts generally agree that routine universal S aureus preoperative
screening is not necessary before lower-risk procedures.78,79 Nevertheless, some
hospitals may consider screening and decolonization for certain patients and pro-
cedures depending on SSI rates caused by S aureus; patient-specific risk factors
for S aureus SSI; and availability of resources to reliably screen, follow up screening
results, and implement protocolized decolonization strategies for patients found to
have nasal S aureus carriage. In addition, although decolonization protocols typically
recommend preoperative application of 2% nasal mupirocin twice daily for several
days close to the date of planned surgery,80 application of intranasal povidone-
iodine swabs on the day of surgery shortly before incision may be an effective, more
practical, and less expensive alternative that precludes concerns regarding resis-
tance to mupirocin.91,92
Colorectal surgery bundles

Multiple studies have shown the potential for implementation of colorectal surgery
best-practice bundles to improve outcomes, including SSI rates.93 Colorectal surgery
bundles commonly include elements of the 9 core best practices for SSI prevention
detailed in this article, as well as additional, less-proven interventions. Based on suc-
cess of bundles, theoretic benefit, and low risk of harm, the authors support imple-
mentation of additional strategies to be included for bundles for colorectal SSI
prevention, such as gown and glove change before fascial and skin closure and use
of a dedicated wound closure tray.
Operating room traffic control

Increased operating room foot traffic and door openings can disrupt air quality and
flow, potentially increasing microbial concentrations at the surgical site and SSI
risk.36,37 The authors support interventions designed to decrease unnecessary oper-
ating room traffic and door openings.
Operating room disinfection

Attention must be paid to operating room maintenance and care, including air handling
and disinfection of the environment and equipment.14,78 Adjunctive disinfection prac-
tices, such as use of ultraviolet light in the operating room, might provide additional
benefit but require further study.94
Controversies
Preoperative chlorhexidine gluconate bathing
Although all patients should receive a bath or shower the night before or evening of
surgery, insufficient evidence exists to recommend universal preoperative use of
CHG.79 However, if not cost-prohibitive, CHG is a reasonable agent to use for preop-
erative bathing. Use of 2% CHG-impregnated cloths may provide greater reduction in
SSI risk than use of CHG soap.95
Local antibiotics
Local and topical antibiotics are commonly used during surgery for the purpose of
decreasing SSI risk. However, in general, high-quality data supporting these practices
are sparse. For example, powdered vancomycin is commonly applied to surgical
sites, but available data are insufficient to recommend its widespread use for SSI pre-
vention. Furthermore, use of powdered vancomycin could be associated with local
adverse effects.96 Another example is use of gentamicin-collagen sponges to prevent
SSI. Single-center trials suggested benefit when these sponges were used in colo-
rectal surgery, but a multicenter randomized trial showed harm.78,97 Meta-analyses
have suggested that gentamicin-collagen sponges might be more successful in
decreasing SSI risk following cardiothoracic surgery.98
Surgical wound irrigation

Incisional wounds are commonly irrigated with saline, antiseptics, or antibiotics for the
purpose of SSI prevention. No consensus exists among best irrigation practices for
SSI prevention, and high-quality data are not available to support routine irrigation
with antibiotics. Incisional wound irrigation with povidone-iodine might be more effec-
tive in decreasing SSI risk than saline irrigation, but this topic requires further study.79
Antiseptic drapes
Some surgeons use adhesive plastic incise drapes, often impregnated with an anti-
septic agent. These drapes are applied to patient skin after skin antisepsis is per-
formed, and the surgeon cuts through the drape and skin. Available data do not
support routine use of antiseptic drapes for SSI prevention.78,84
Antiseptic-impregnated sutures
Triclosan-coated sutures are commonly used to decrease SSI risk, but data evaluating
this practice are mixed.99 In addition, limited data have suggested possible negative
effect on wound healing.100 Guideline recommendations regarding triclosan-coated
sutures are contradictory and range from a recommendation against routine use78
to conditional recommendations supporting their use.79,80
Advanced dressings
Advanced dressings for primarily closed surgical wounds, such as silver-containing or
antimicrobial-impregnated dressings, have not been proved to significantly decrease
SSI rates compared with standard dressings.80,84 Regardless of type of dressing
used, dressings should be sterile and be placed and changed using aseptic technique.
Wound protectors
Plastic wound protectors can facilitate retraction of an incision without requiring addi-
tional mechanical retractors and can decrease SSI risk after open abdominal sur-
geries.78,80 Benefit may be greatest for colorectal and biliary tract procedures.
Prophylactic negative pressure wound therapy
Routine use of prophylactic negative pressure wound therapy has not been shown to
decrease SSIs. A recent, large, randomized clinical trial found that there was no sig-
nificant difference in the risk of SSI after cesarean delivery in obese women with pro-
phylactic negative pressure wound therapy (3.6%) versus standard wound dressing
(3.4%).101 Low-quality evidence suggests that prophylactic negative pressure wound
therapy on primarily closed, high-risk surgical wounds decreases SSI risk compared
with use of standard wound dressings.79,80 Examples of high-risk wounds include
wounds complicated by surrounding soft tissue damage, poor blood flow, hematoma,
or intraoperative contamination. The pressure level or duration of negative pressure
therapy needed to maximize SSI risk reduction is not known.
THERAPEUTIC OPTIONS
Surgical debridement and removal of the infected tissue is the most important facet of
therapy for many SSIs, with antimicrobial therapy being an important adjunct compo-
nent.102 However, the type of debridement and duration of antimicrobial therapy
depend on the depth and anatomic site of infection and the presence of prosthetic ma-
terial. However, deep-incisional and organ/space infections almost universally require
operative evacuation of the infected tissue.
Superficial-incisional SSIs can typically be treated with oral antibiotics and without
surgical debridement. In contrast, patients with systemic symptoms
(temperature >38.5 C, heart rate >110 beats/min) or with suspected deep-incisional
or organ/space SSI generally require exploration of the surgical site in addition to an-
tibiotics.102 The specific antibiotic and duration of therapy are determined by the loca-
tion of the infection, the depth of infection, the adequacy of surgical debridement, and
resistance patterns of the causative pathogens. However, in general, clinicians should
initiate systemic antibiotic therapy when a patient has systemic symptoms of infection
or a clinician suspects a deep-incision or organ/space SSI. For example, 1 study found
that patients with mediastinitis who receive antibiotics active against the identified
pathogen within 7 days of debridement had a 60% reduction in mortality compared
with patients who did not receive effective antibiotic therapy.103
ASSESSMENT
The CDC conducted the Study of the Efficacy of Nosocomial Infection Control
(SENIC) to determine the cost-effectiveness of infection prevention activities,
including surveillance.104 These and many subsequent studies concluded that infec-
tion surveillance programs and feedback of SSI rates to surgeons decrease overall
SSI rates by 32% to 50%.105,106 These data form the basis for the CDC’s recommen-
dation that hospitals routinely perform surveillance for SSIs and report the informa-
tion back to surgeons.14
Surveillance Methodology
Strategies for targeting surveillance by procedure type
Given the significant resources required to perform SSI surveillance, many infection
prevention programs focus their SSI surveillance efforts on a subset of patients. Hos-
pitals may determine surgical populations for targeted surveillance in several ways.
One strategy is to target high-volume surgical procedures for surveillance, because
SSIs related to these procedures would pose risk to a large number of patients. Exam-
ples of high-volume procedures include colorectal procedures, abdominal hysterec-
tomies, and hip and knee arthroscopies. Notably, US hospitals are required to
publicly report rates of SSI following colorectal and abdominal hysterectomy proced-
ures. Another strategy is to target high-risk procedures for surveillance, because SSIs
after these procedures convey high risk of morbidity. Examples of high-risk proced-
ures include spinal fusion and craniotomies. A third strategy is to focus surveillance
efforts on surgical procedures that have rates of SSI that are higher than expected
at that institution (based on historical comparisons). Typically, infection prevention
programs use a combination of these targeting strategies.
Strategies for surgical site infection case finding
Direct prospective case finding through daily chart review and observation of the sur-
gical site by infection prevention personnel is considered the most sensitive and
rigorous method to identify patients with SSI.106 However, direct surveillance is no
longer practiced for several reasons. First, daily observation of the wound is resource
intensive and impractical for modern infection prevention programs. Second, indirect
methods that involve medical record review without direct wound observation have
shown sensitivity of 84% to 89% and specificity of 99.8%, and they require fewer re-
sources compared with direct observation.107,108 In addition, most SSIs occur
following discharge from the index hospitalization and can only be detected through
postdischarge surveillance methods.109
Many infection prevention programs screen records for possible indicators of SSI
and proceed with complete chart review only when an indicator is present. NHSN sug-
gests several methods to identify patients with possible SSI, including review of med-
ical records for signs and symptoms of SSI; review of admission, readmission,
emergency room visits, and operating room logs; review of laboratory, imaging, or
other diagnostic test reports; review of clinician notes; International Classification of
Diseases-10 Clinical Modification (ICD-10-CM) Infection Diagnosis codes; surgeon
surveys; and patient surveys.16 However, NHSN states that facilities may use any
combination of methods to identify potential patients with SSI. Therefore, consider-
able variability among case-finding methods across facilities exists.
Microbiology data
Many SSI surveillance programs use positive microbiology results as an indicator of
possible SSI. However, microbiology data are not perfect indicators of SSI because
cultures or other microbiology studies are not obtained in every case; superficial
wound infections are frequently treated with local wound management with or without
antibiotics. Studies have shown that surveillance systems that rely solely on microbi-
ologic data only identify 33% to 65% of all SSIs.110
Antimicrobial administration
Antibiotic use beyond the expected number of postoperative days (used for perioper-
ative prophylaxis) can be used to predict SSI.110,111 However, postoperative antibiotic
use alone is not sensitive or specific for SSI detection. Some patients continue to
receive antibiotics following a surgical procedure for prophylaxis or treatment of a pre-
existing infection. In addition, antibiotics are not always required for management of
superficial SSIs.102 Therefore, antibiotics should only be used in combination with
other parameters to screen patients for possible SSI.
Administrative claims data

Several studies have evaluated the utility of using administrative billing data as an in-
dicator of SSI.111–113 Using administrative claims data increases detection of SSIs
relative to standard surveillance methods.114 In addition, studies have found that using
administrative data as a flag for further chart review by infection preventionists saves
time and significantly decreases the burden of surveillance compared with standard
methods.113,114 In addition, US Centers for Medicare and Medicaid Services (CMS)
Medicare claims data can be used to accurately distinguish between hospitals with
high and low rates of infection following certain procedure types.
However, several limitations to using administrative data to facilitate surveillance
exist. First, billing is performed retroactively. Therefore, surveillance systems that
rely on administrative data as the first trigger to review charts for SSI cannot detect
SSI in real time and intervene or provide feedback in a timely manner. Second, recent
studies of administrative data for SSI surveillance have typically been performed on
clean procedures, including cardiac, arthroplasty, vascular, and breast procedures.
The utility of administrative billing data as an indicator of SSI following other procedure
types is unclear.
Electronic surveillance
With the evolution of the electronic medical record, infection prevention programs and
software vendors are exploring automated methods to detect patients with SSI. How-
ever, at this time, no single effective SSI prediction tool exists. For example, 1 study of
an automated algorithm that used specified laboratory parameters and antimicrobial
use to detect SSIs found the model performed poorly, with overall sensitivity of
37.8%, and had poor interhospital ability to generalize.115 Development of electronic
surveillance tools with improved accuracy is an area of ongoing research.
Surgical site infection metrics and data feedback

SSI rates are typically calculated per 100 procedures and may be stratified by proced-
ure type and surgeon. SSI rates should be periodically assessed for trends and re-
ported to surgeons, perioperative services staff, and hospital leaders. Peer-to-peer
comparative SSI rate data may be helpful to identify surgeons whose rates are higher
than those of peers; however, without adequate adjustment for difference in patient-
level or procedure-level risk factors, peer-to-peer comparative data should be used
for performance improvement purposes only.
Surveillance systems that detect SSIs in near real time allow for concurrent feed-
back to surgical and perioperative personnel as SSIs are identified. This type of sur-
veillance allows performance improvement teams to investigate for potential lapses
in patient care (eg, missed administration of perioperative antibiotic, failure to main-
tain postoperative glucose control) and take actions to improve compliance with rec-
ommended best practices. Because SSIs are low-frequency events, it can
sometimes be difficult for infection prevention and perioperative teams to detect
when there is a meaningful increase or cluster of infections over baseline. Use of sta-
tistical process control charts to analyze SSI surveillance data and alert staff when a
potential cluster has occurred may promote earlier detection of important SSI rate
increases.116
In summary, surveillance for SSI and data feedback are important functions of infec-
tion prevention teams. However, methods for conducting surveillance and the quality
of surveillance vary across health care facilities and depend on availability of re-
sources. Infection prevention programs should periodically evaluate their surveillance
programs to ensure they are maximally effective and reflect the most recent recom-
mended best practices for SSI prevention.
SUMMARY
SSIs are the most common and costly health care–associated infections in the United
States1,2,7 and lead to significant patient morbidity and mortality.4,11 However,
adhering to evidence-based preventive practices can decrease the rate of SSI. In gen-
eral, aggressive surgical debridement in addition to appropriate antibiotic therapy is
necessary for SSI treatment.
CLINICS CARE POINTS
Before surgical incision, patients need to receive the appropriate type and dose of antibiotic
within the appropriate time frame. Patients may also require additional antibiotic doses for
prolonged procedures.
Perioperative staff should only remove patient hair if it interferes with the surgery, and, even
then, hair removal should be done with a clipper or depilatory agent outside of the
operating room.
The skin over the surgical site needs to be cleansed with an alcohol-containing antiseptic
solution.
Providers must perform hand preparation with a suitable antimicrobial soap or alcohol-
based hand rub before entering the operating room.
During the operation, every effort should be made to maintain normothermia,
hyperoxygenation, and normal glucose levels.
Hospitals should use surgical safety checklists to improve compliance with practices for SSI
prevention.
DISCLOSURE
Dr Anderson reported grants from CDC Epicenter (U54CK000483) during the conduct
of the study; grants from Agency for Healthcare Research and Quality, personal fees
from UpToDate, and royalties for authorship outside the submitted work.
REFERENCES
1. Lewis SS, Moehring RW, Chen LF, et al. Assessing the relative burden of
hospital-acquired infections in a network of community hospitals. Infect Control
Hosp Epidemiol 2013;34(11):1229–30.
2. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a
meta-analysis of costs and financial impact on the US health care system. JAMA
Intern Med 2013;173(22):2039–46.
3. Steiner CA, Karaca Z, Moore BJ, et al. STATISTICAL BRIEF# 223. 2017.
4. Agency for Healthcare Research and Quality. Healthcare cost and utilization
project - statistics on hospital stays. 2013 web site. Available at: http://
hcupnet.ahrq.gov/. Accessed November 17, 2020.
5. Scott RD. The direct medical costs of healthcare-associated infections in US
hospitals and the benefits of prevention 2009. Available at: https://www.cdc.
gov/hai/pdfs/hai/scott_costpaper.pdf.
6. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-
care-associated infection in developing countries: systematic review and meta-
analysis. Lancet 2011;377(9761):228–41.
7. Magill SS, O’Leary E, Janelle SJ, et al. Changes in prevalence of health care–
associated infections in US Hospitals. N Engl J Med 2018;379(18):1732–44.
8. Geubbels EL, Wille JC, Nagelkerke NJ, et al. Hospital-related determinants for
surgical-site infection following hip arthroplasty. Infect Control Hosp Epidemiol
2005;26(5):435–41.
9. Baker AW, Dicks KV, Durkin MJ, et al. Epidemiology of surgical site infection in a
community hospital network. Infect Control Hosp Epidemiol 2016;37(5):519–26.
10. Anderson DJ, Hartwig MG, Pappas T, et al. Surgical volume and the risk of sur-
gical site infection in community hospitals: size matters. Ann Surg 2008;247(2):
343–9.
11. Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to
methicillin resistant Staphylococcus aureus surgical site infection: a multi-
center matched outcomes study. PLoS One 2009;4(12):e8305.
12. Martone WJ, Nichols RL. Recognition, prevention, surveillance, and manage-
ment of surgical site infections: introduction to the problem and symposium
overview. Clin Infect Dis 2001;33(Suppl 2):S67–8.
13. Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical-site infections in
the 1990s: attributable mortality, excess length of hospitalization, and extra
costs. Infect Control Hosp Epidemiol 1999;20(11):725–30.
14. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol 1999;20(4):247–80.
15. Estimating the additional hospital inpatient cost and mortality associated with
selected hospital-acquired conditions. Agency for healthcare research and
quality. 2017. Available at: https://www.ahrq.gov/hai/pfp/haccost2017-results.
html. Accessed October 20, 2019.
16. Centers for Disease Control and Prevention. Surgical Site Infection (SSI) event
web site. Available at: https://www.cdc.gove/nhsn/pdfs/pscmanual/
9pscssicurrent.pdf. Accessed November 20, 2020.
17. Dicks KV, Lewis SS, Durkin MJ, et al. Surveying the surveillance: surgical site
infections excluded by the January 2013 updated surveillance definitions. Infect
Control Hosp Epidemiol 2014;35(5):570–3.
18. Wenzel RP. Surgical site infections and the microbiome: an updated perspec-
tive. Infect Control Hosp Epidemiol 2019;40(5):590–6.
19. Seidelman JL, Baker AW, Ge M, et al. 905. Surgical site infections following co-
lon surgery in a large network of community hospitals. Open Forum Infect Dis
2020;7(Supplement_1):S486–7.
20. Baker AW, Lewis SS, Alexander BD, et al. Two-phase hospital-associated
outbreak of Mycobacterium abscessus: investigation and mitigation. Clin Infect
Dis 2017;64(7):902–11.
21. Everett ED, Pearson S, Rogers W. Rhizopus surgical wound infection with elas-
ticized adhesive tape dressings. Arch Surg 1979;114(6):738–9.
22. Wenger PN, Brown JM, McNeil MM, et al. Nocardia farcinica sternotomy site in-
fections in patients following open heart surgery. J Infect Dis 1998;178(5):
1539–43.
23. Leaper D, Edmiston C. World Health Organization: global guidelines for the pre-
vention of surgical site infection. J Hosp Infect 2017;95(2):135–6.
24. Lee KY, Coleman K, Paech D, et al. The epidemiology and cost of surgical site
infections in Korea: a systematic review. J Korean Surg Soc 2011;81(5):
295–307.
25. Fleischmann W, Meyer H, Baer A. Bacterial recolonization of the skin under a
Polyurethane drape in hip surgery. J Hosp Infect 1996;34(2):107–16.
26. Seropian R, Reynolds BM. Wound infections after preoperative depilatory
versus razor preparation. Am J Surg 1971;121(3):251–4.
27. Ko W, Lazenby WD, Zelano JA, et al. Effects of shaving methods and intraoper-
ative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac
Surg 1992;53(2):301–5.
28. Korol E, Johnston K, Waser N, et al. A systematic review of risk factors associ-
ated with surgical site infections among surgical patients. PLoS One 2013;8(12):
e83743.
29. Berard F, Gandon J. Postoperative wound infections: the influence of ultraviolet
irradiation of the operating room and of various other factors. Ann Surg 1964;
160(Suppl 2):1–192.
30. Elek SD, Conen PE. The virulence of Staphylococcus pyogenes for man; a study
of the problems of wound infection. Br J Exp Pathol 1957;38(6):573–86.
31. Davidson T, Lewandowski E, Smerecki M, et al. Taking your work home with you:
potential risks of contaminated clothing and hair in the dental clinic and attitudes
about infection control. Can J Infect Control 2017;32(3):137–42.
32. Fagernes M, Lingaas E. Factors interfering with the microflora on hands: a
regression analysis of samples from 465 healthcare workers. J Adv Nurs
2011;67(2):297–307.
33. Parry MF, Grant B, Yukna M, et al. Candida osteomyelitis and diskitis after spinal
surgery: an outbreak that implicates artificial nail use. Clin Infect Dis 2001;32(3):
352–7.
34. Lidwell OM, Lowbury EJ, Whyte W, et al. Airborne contamination of wounds in
joint replacement operations: the relationship to sepsis rates. J Hosp Infect
1983;4(2):111–31.
35. Edmiston CE Jr, Seabrook GR, Cambria RA, et al. Molecular epidemiology of mi-
crobial contamination in the operating room environment: Is there a risk for infec-
tion? Surgery 2005;138(4):573–9 [discussion: 579–582].
36. Roth JA, Juchler F, Dangel M, et al. Frequent door openings during cardiac sur-
gery are associated with increased risk for surgical site infection: a prospective
observational study. Clin Infect Dis 2019;69(2):290–4.
37. Andersson AE, Bergh I, Karlsson J, et al. Traffic flow in the operating room: an
explorative and descriptive study on air quality during orthopedic trauma
implant surgery. Am J Infect Control 2012;40(8):750–5.
38. Manian FA. The role of postoperative factors in surgical site infections: time to
take notice. Clin Infect Dis 2014;59(9):1272–6.
39. Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical
site infection. Cochrane Database Syst Rev 2016;12:CD003091.
40. Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following intra-
articular steroid injection of the knee–a survey of current practice regarding anti-
septic technique used during intra-articular steroid injection of the knee. Clin
Rheumatol 2003;22(6):386–90.
41. McIntosh AL, Hanssen AD, Wenger DE, et al. Recent intraarticular steroid injec-
tion may increase infection rates in primary THA. Clin Orthop Relat Res 2006;
451:50–4.
42. Desai A, Ramankutty S, Board T, et al. Does intraarticular steroid infiltration in-
crease the rate of infection in subsequent total knee replacements? Knee
2009;16(4):262–4.
43. Jevsevar DS, Brown GA, Jones DL, et al. The American Academy of Orthopae-
dic Surgeons evidence-based guideline on: treatment of osteoarthritis of the
knee. J Bone Joint Surg Am 2013;95(20):1885–6.
44. Yin JB, Cui GB, Mi MS, et al. Local infiltration analgesia for postoperative pain
after hip arthroplasty: a systematic review and meta-analysis. J Pain 2014;
15(8):781–99.
45. Seidelman J, Baker AW, Anderson DJ, et al. Do periarticular joint infections pre-
sent an increase in infection risk? Infect Control Hosp Epidemiol 2018;39(7):
890–1.
46. Kaye KS, Anderson DJ, Sloane R, et al. The effect of surgical site infection on
older operative patients. J Am Geriatr Soc 2009;57(1):46–54.
47. Fore J. A review of skin and the effects of aging on skin structure and function.
Ostomy Wound Manage 2006;52(9):24–35, quiz 36–37.
48. Reddy M. Skin and wound care: important considerations in the older adult. Adv
Skin Wound Care 2008;21(9):424–36, quiz 437–438.
49. Kaye KS, Schmit K, Pieper C, et al. The effect of increasing age on the risk of
surgical site infection. J Infect Dis 2005;191(7):1056–62.
50. Olsen MA, Lefta M, Dietz JR, et al. Risk factors for surgical site infection after
major breast operation. J Am Coll Surg 2008;207(3):326–35.
51. Faraday N, Rock P, Lin EE, et al. Past history of skin infection and risk of surgical
site infection after elective surgery. Ann Surg 2013;257(1):150–4.
52. Zhang Y, Zheng QJ, Wang S, et al. Diabetes mellitus is associated with
increased risk of surgical site infections: a meta-analysis of prospective cohort
studies. Am J Infect Control 2015;43(8):810–5.
53. Martin ET, Kaye KS, Knott C, et al. Diabetes and risk of surgical site infection: a
systematic review and meta-analysis. Infect Control Hosp Epidemiol 2016;37(1):
88–99.
54. Turina M, Fry DE, Polk HC Jr. Acute hyperglycemia and the innate immune sys-
tem: clinical, cellular, and molecular aspects. Crit Care Med 2005;33(7):
1624–33.
55. Dronge AS, Perkal MF, Kancir S, et al. Long-term glycemic control and postop-
erative infectious complications. Arch Surg 2006;141(4):375–80 [discus-
sion: 380].
56. Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and
glucose control with surgical-site infections among cardiothoracic surgery pa-
tients. Infect Control Hosp Epidemiol 2001;22(10):607–12.
57. Hennessey DB, Burke JP, Ni-Dhonochu T, et al. Preoperative hypoalbuminemia
is an independent risk factor for the development of surgical site infection
following gastrointestinal surgery: a multi-institutional study. Ann Surg 2010;
252(2):325–9.
58. Testini M, Margari A, Amoruso M, et al. [The dehiscence of colorectal anastomo-
ses: the risk factors]. Ann Ital Chir 2000;71(4):433–40.
59. Rivadeneira DE, Grobmyer SR, Naama HA, et al. Malnutrition-induced macro-
phage apoptosis. Surgery 2001;129(5):617–25.
60. Runyon BA. Low-protein-concentration ascitic fluid is predisposed to sponta-
neous bacterial peritonitis. Gastroenterology 1986;91(6):1343–6.
61. Wukich DK, McMillen RL, Lowery NJ, et al. Surgical site infections after foot and
ankle surgery: a comparison of patients with and without diabetes. Diabetes
Care 2011;34(10):2211–3.
62. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces inci-
sional wound infection: a randomized controlled trial. Ann Surg 2003;238(1):1.
63. Sorensen LT. Wound healing and infection in surgery: the pathophysiological
impact of smoking, smoking cessation, and nicotine replacement therapy: a
systematic review. Ann Surg 2012;255(6):1069–79.
64. Yuan K, Chen HL. Obesity and surgical site infections risk in orthopedics: a
meta-analysis. Int J Surg 2013;11(5):383–8.
65. Wick EC, Hirose K, Shore AD, et al. Surgical site infections and cost in obese
patients undergoing colorectal surgery. Arch Surg 2011;146(9):1068–72.
66. Harrington G, Russo P, Spelman D, et al. Surgical-site infection rates and risk
factor analysis in coronary artery bypass graft surgery. Infect Control Hosp Epi-
demiol 2004;25(6):472–6.
67. Meijs AP, Koek MBG, Vos MC, et al. The effect of body mass index on the risk of
surgical site infection. Infect Control Hosp Epidemiol 2019;40(9):991–6.
68. Filsoufi F, Rahmanian PB, Castillo JG, et al. Incidence, treatment strategies and
outcome of deep sternal wound infection after orthotopic heart transplantation.
J Heart Lung Transpl 2007;26(11):1084–90.
69. Payne WG, Naidu DK, Wheeler CK, et al. Wound healing in patients with cancer.
Eplasty 2008;8:e9.
70. Corcoran TB, Myles PS, Forbes AB, et al. Dexamethasone and Surgical-Site
Infection. N Engl J Med 2021;384(18):1731–41.
71. Bosanquet DC, Rangaraj A, Richards AJ, et al. Topical steroids for chronic
wounds displaying abnormal inflammation. Ann R Coll Surg Engl 2013;95(4):
291–6.
72. Hopf HW, Holm J. Hyperoxia and infection. Best Pract Res Clin Anaesthesiol
2008;22(3):553–69.
73. Wetterslev J, Meyhoff CS, Jørgensen LN, et al. The effects of high perioperative
inspiratory oxygen fraction for adult surgical patients. Cochrane Database Syst
Rev 2015;(6). Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/
14651858.CD008884.pub2/abstract?cookiesEnabled.
74. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the inci-
dence of surgical-wound infection and shorten hospitalization. Study of Wound
Infection and Temperature Group. N Engl J Med 1996;334(19):1209–15.
75. Wang Z, Anderson FA Jr, Ward M, et al. Surgical site infections and other post-
operative complications following prophylactic anticoagulation in total joint ar-
throplasty. PLoS One 2014;9(4):e91755.
76. Rohde JM, Dimcheff DE, Blumberg N, et al. Health care-associated infection af-
ter red blood cell transfusion: a systematic review and meta-analysis. JAMA
2014;311(13):1317–26.
77. Muszynski J, Nateri J, Nicol K, et al. Immunosuppressive effects of red blood
cells on monocytes are related to both storage time and storage solution. Trans-
fusion 2012;52(4):794–802.
78. Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical
site infections in acute care hospitals: 2014 update. Infect Control Hosp Epide-
miol 2014;35(Suppl 2):S66–88.
79. Global guidelines for the prevention of surgical site infection, second edition.
Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. p.
58–158.
80. Ban KA, Minei JP, Laronga C, et al. American college of surgeons and surgical
infection society: surgical site infection guidelines, 2016 update. J Am Coll Surg
2017;224(1):59–74.
81. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for disease control
and prevention guideline for the prevention of surgical site infection, 2017.
JAMA Surg 2017;152(8):784–91.
82. Seal LA, Paul-Cheadle D. A systems approach to preoperative surgical patient
skin preparation. Am J Infect Control 2004;32(2):57–62.
83. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for anti-
microbial prophylaxis in surgery. Am J Health Syst Pharm 2013;70(3):195–283.
84. Global guidelines for the prevention of surgical site infection. Geneva
(Switzerland): World Health Organization; 2018. Available at: https://www.ncbi.
nlm.nih.gov/books/NBK536404/.
85. Jones EL, Overbey DM, Chapman BC, et al. Operating room fires and surgical
skin preparation. J Am Coll Surg 2017;225(1):160–5.
86. Tuuli MG, Liu J, Stout MJ, et al. A randomized trial comparing skin antiseptic
agents at cesarean delivery. N Engl J Med 2016;374(7):647–55.
87. Prevention of infection after gynecologic procedures. The American College of
Obstetricians and Gynecologists. ACOG practice bulletin. Number 195. 2018.
Available at: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/
articles/2018/06/prevention-of-infection-after-gynecologic-procedures.
88. Haas DM, Morgan S, Contreras K, et al. Vaginal preparation with antiseptic so-
lution before cesarean section for preventing postoperative infections. Co-
chrane Database Syst Rev 2018;7:Cd007892.
89. Myles PS, Carlisle JB, Scarr B. Evidence for compromised data integrity in
studies of liberal peri-operative inspired oxygen. Anaesthesia 2019;74(5):
573–84.
90. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce
morbidity and mortality in a global population. N Engl J Med 2009;360(5):491–9.
91. Phillips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a
randomized, open-label trial of nasal mupirocin ointment and nasal povidone-
iodine solution. Infect Control Hosp Epidemiol 2014;35(7):826–32.
92. Rezapoor M, Nicholson T, Tabatabaee RM, et al. Povidone-iodine-based solu-
tions for decolonization of nasal staphylococcus aureus: a randomized, pro-
spective, placebo-controlled study. J Arthroplasty 2017;32(9):2815–9.
93. Keenan JE, Speicher PJ, Nussbaum DP, et al. Improving outcomes in colorectal
surgery by sequential implementation of multiple standardized care programs.
J Am Coll Surg 2015;221(2):404–14.e401.
94. Cook TM, Piatt CJ, Barnes S, et al. The impact of supplemental intraoperative air
decontamination on the outcome of total joint arthroplasty: a pilot analysis.
J Arthroplasty 2019;34(3):549–53.
95. Graling PR, Vasaly FW. Effectiveness of 2% CHG cloth bathing for reducing sur-
gical site infections. AORN J 2013;97(5):547–51.
96. Baker AW, Chen LF. Letter to the editor regarding: "Effectiveness of local vanco-
mycin powder to decrease surgical site infections: a meta-analysis" by Chiang
et al. Spine J 2014;14(6):1092.
97. Bennett-Guerrero E, Pappas TN, Koltun WA, et al. Gentamicin-collagen sponge
for infection prophylaxis in colorectal surgery. N Engl J Med 2010;363(11):
1038–49.
98. Kowalewski M, Pawliszak W, Zaborowska K, et al. Gentamicin-collagen sponge
reduces the risk of sternal wound infections after heart surgery: Meta-analysis.
J Thorac Cardiovasc Surg 2015;149(6):1631–40.e1631.
99. Wu X, Kubilay NZ, Ren J, et al. Antimicrobial-coated sutures to decrease surgi-
cal site infections: a systematic review and meta-analysis. Eur J Clin Microbiol
2017;36(1):19–32.
100. Deliaert AE, Van den Kerckhove E, Tuinder S, et al. The effect of triclosan-coated
sutures in wound healing. A double blind randomised prospective pilot study.
J Plast Reconstr Aesthet Surg 2009;62(6):771–3.
101. Tuuli MG, Liu J, Tita ATN, et al. Effect of prophylactic negative pressure wound
therapy vs standard wound dressing on surgical-site infection in obese women
after cesarean delivery: a randomized clinical trial. JAMA 2020;324(12):1180–9.
102. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis
and management of skin and soft tissue infections: 2014 update by the Infec-
tious Diseases Society of America. Clin Infect Dis 2014;59(2):e10–52.
103. Karra R, McDermott L, Connelly S, et al. Risk factors for 1-year mortality after
postoperative mediastinitis. J Thorac Cardiovasc Surg 2006;132(3):537–43.
104. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and
control programs in preventing nosocomial infections in US hospitals. Am J Epi-
demiol 1985;121(2):182–205.
105. Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective
study of 62,939 wounds. Surg Clin North Am 1980;60(1):27–40.
106. Olson MM, Lee JT Jr. Continuous, 10-year wound infection surveillance. Results,
advantages, and unanswered questions. Arch Surg 1990;125(6):794–803.
107. Baker C, Luce J, Chenoweth C, et al. Comparison of case-finding methodolo-
gies for endometritis after cesarean section. Am J Infect Control 1995;23(1):
27–33.
108. Cardo DM, Falk PS, Mayhall CG. Validation of surgical wound surveillance.
Infect Control Hosp Epidemiol 1993;14(4):211–5.
109. Ming DY, Chen LF, Miller BA, et al. The impact of depth of infection and postdi-
scharge surveillance on rate of surgical-site infections in a network of commu-
nity hospitals. Infect Control Hosp Epidemiol 2012;33(3):276–82.
110. Wenzel RP, Osterman CA, Hunting KJ, et al. Hospital-acquired infections. I. Sur-
veillance in a university hospital. Am J Epidemiol 1976;103(3):251–60.
111. Yokoe DS, Noskin GA, Cunningham SM, et al. Enhanced identification of post-
operative infections among inpatients. Emerg Infect Dis 2004;10(11):1924–30.
112. Platt R, Kleinman K, Thompson K, et al. Using automated health plan data to
assess infection risk from coronary artery bypass surgery. Emerg Infect Dis
2002;8(12):1433–41.
113. Inacio MC, Paxton EW, Chen Y, et al. Leveraging electronic medical records for
surveillance of surgical site infection in a total joint replacement population.
Infect Control Hosp Epidemiol 2011;32(4):351–9.
114. Bolon MK, Hooper D, Stevenson KB, et al. Improved surveillance for surgical
site infections after orthopedic implantation procedures: extending applications
for automated data. Clin Infect Dis 2009;48(9):1223–9.
115. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depres-
sion in men vs women: analysis of the National Comorbidity Survey Replication.
JAMA Psychiatry 2013;70(10):1100–6.
116. Baker AW, Haridy S, Salem J, et al. Performance of statistical process control
methods for regional surgical site infection surveillance: a 10-year multicentre
pilot study. BMJ Qual Saf 2018;27(8):600–10.
117. Dumville JC, McFarlane E, Edwards P, et al. Preoperative skin antiseptics for
preventing surgical wound infections after clean surgery. Cochrane Database
Syst Rev 2013;(3):CD003949.
118. McLaws ML, Murphy C, Whitby M. Standardising surveillance of nosocomial in-
fections: the HISS program. Hospital infection standardised surveillance. J Qual
Clin Pract 2000;20(1):6–11.

Surgical-Site-Infections_2021_Infectious-Disease-Clinics-of-North-America

Uploaded by

Copyright:

Available Formats

Surgical-Site-Infections_2021_Infectious-Disease-Clinics-of-North-America

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Surgical-Site-Infections_2021_Infectious-Disease-Clinics-of-North-America

Uploaded by

Copyright:

Available Formats

Surgical Site Infections

Infect Dis Clin N Am 35 (2021) 901–929

Clinically, a surgical wound is considered infected when purulent drainage is present

and other fungi, Nocardia, Rhodococcus, and nontuberculous mycobacteria

Superficial Incisional Deep Incisional Organ/Space

Preoperative hair removal

Clean Cardiac Bypass

Abbreviation: MSSA, methicillin-sensitive S aureus.

Wound contamination from operating room personnel

Intra-articular steroid injections

Patient Related, Nonmodifiable

Risk Factor Pathophysiology

(continued on next page)

(continued on next page)

History of prior skin and soft tissue infection

Patient Related, Modifiable

GUIDELINES FOR PREVENTION

(continued on next page)

(continued on next page)

Abbreviation: FiO2, fraction of inspired oxygen.

Perioperative preparation of operative site

Surgical hand preparation

benefit of hyperoxygenation may be greatest for open colorectal surgery. Updated

Staphylococcus aureus screening and decolonization

Colorectal surgery bundles

Operating room traffic control

Operating room disinfection

Surgical wound irrigation

Administrative claims data

Surgical site infection metrics and data feedback

CLINICS CARE POINTS

You might also like