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TWENTY-THREE

PREVENTING SURGICAL SITE INFECTIONS
KEY CONCEPTS you will learn in this chapter include: What the factors that affect the risk of nosocomial surgical site infections are How to reduce the risk of nosocomial surgical site infections What the rationale for antibiotic prophylaxis is When the use of prophylactic antibiotics is indicated What the recommendations for prevention ofbacterial endocarditis are BACKGROUND Before the work of Joseph Lister and others in the 1860s, surgical patients commonly developed postoperative fever followed by purulent drainage from their incisions, sepsis and often death. The introduction of the principles of antisepsis by Lister and the acceptance of Pasteur’s germ theory in the late nineteenth century led to a marked decrease in woundinfection rates. These discoveries also radically changed surgery from an activity associated with infection and death to one of preventing suffering and prolonging life. In the twentieth century, the two key factors that have enabled surgical advances, such as open heart surgery and kidney transplants, to become routinely possible and safe are improved anesthesia and scientifically sound infectionprevention practices. Despite improvements in operating room practices, instrument sterilization methods, better surgical technique and the best efforts of infection prevention practitioners, surgical site infections (SSIs) remain a major cause of nosocomial (hospital-acquired) infections—and rates are increasing globally (Alvarado 2000). Moreover, in countries where resources are limited, evenbasic life-saving operations, such as appendectomies and cesarean sections, are associated with high infection rates and mortality. In these countries, therefore, it makes sense to focus on preventing SSIs in those procedures most frequently performed and/or those having the highest SSI rates. To reduce the risk of nosocomial SSIs in developing countries, a systematic but realistic approach must beapplied with awareness that this risk is influenced by characteristics of the patient, the operation, the healthcare staff and the hospital. In theory, reducing risk is relatively simple and inexpensive, especially when compared to the cost of the infections themselves, but in practice it requires commitment at all levels of the healthcare system. And, as noted in Chapter 20, neither the basicInfection Prevention Guidelines

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Preventing Surgical Site Infections

problems responsible for the high nosocomial rates (i.e., lack of training, supervision, infrastructure and resources) nor the recommended solutions have changed over the past 10–20 years in most developing countries. DEFINITIONS Organ/Space SSI. Any part of the body other than the incised body wall parts thatwere opened or handled during an operation. Surgical site infections (SSI). Either an incisional or organ/space infection occurring within 30 days after an operation or within 1 year if an implant is present. As shown in Figure 23-1, incisional SSIs are further divided into superficial incisional (only involves skin and subcutaneous tissue)1 and deep incisional (involves deeper soft tissue,including fascia and muscle layers).2
Figure 23-1. Cross-Section of Abdominal Wall Showing CDC Classifications of Surgical Site Infection

Adapted from: Horan et al 1992.

1

Does not include stitch abscess, infection of episiotomy or newborn circumcision, or infected burn wound. Specific criteria are used for identifying these infections and reporting them. 2 For confirmation of all SSIs,clinical findings (signs or symptoms of infections) and/or laboratory test results (organism isolated from aseptically obtained culture) are required.

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Infection Prevention Guidelines

Preventing Surgical Site Infections

The surgical wound classification system includes four categories: Class I—clean. Uninfected operative wound with no inflammation and in which the respiratory,...