Surgical Site Infections
Section snippets
Definitions
What constitutes an SSI? Even experts disagree with respect to the appearance of the incision [2]. Is it cellulitis of the incision without drainage, or nonpurulent drainage without cellulitis? Is any incision infected that must be reopened, or is the requirement for antimicrobial therapy the best indicator? Most experts agree that surgical sites that do not harbor purulent fluid are not infected, but the lack of agreement otherwise means that any retrospective study of SSI is essentially
Epidemiology
Issues related to bacterial contamination of the surgical site have been well defined [2]. Clean surgical procedures are those where the operation has affected only integumentary and musculoskeletal soft tissues. Clean-contaminated procedures are those where a hollow viscus (eg, alimentary, biliary, genitourinary, respiratory tract) has been opened under controlled circumstances (eg, elective colon surgery). Contaminated procedures are those where bacteria has been introduced extensively into a
Microbiology
Inoculation of the surgical site occurs during surgery, either inward from the skin or outward from the internal organ being operated on, hence the rationale for skin preparation and bowel preparation with antiseptics or antibiotics, and prophylactic oral or parenteral administration of antibiotic prophylaxis. The microbiology of SSI depends on the type of operation being performed, with an increased likelihood of infection caused by gram-negative bacilli after gastrointestinal surgery.
Preoperative preparation
The patient should be assessed for factors that can be corrected in the preoperative period before elective surgery. Open skin lesions should be allowed to heal if possible, and the patient should be free of bacterial infections of any kind. The patient should quit smoking if possible, preferably one month before surgery. The patient should shower with an antibacterial soap the night before the operation. The patient must not be shaved the night before, as the risk of SSI is clearly increased
The operating room environment
Much of what is taken for granted in the modern operating room can, if lapses occur, result in increased rates of SSI. The elements of proper operating room design, management, and comportment have been reviewed with a close look at supporting evidence [16].
Although such factors as proper sterilization technique and ventilation should not be the everyday concern of the surgeon, operating room personnel must remain vigilant. The surgeon must be attentive to his or her personal hygiene (eg, hand
Management of the incision
Cosmesis is important to patients, who naturally want wounds to be closed for the sake of appearance. On the other hand, closure of a contaminated or dirty wound is widely believed to increase the risk of SSI. This conflict poses a dilemma for surgeons. The search goes on for innovative methods or adjuncts to wound closure that will both promote healing and ease cosmetic concerns. Few good studies exist to help sort out the multiplicity of techniques, making this an area where tradition and
Blood transfusion
In surgery and trauma, blood transfusions are common and may be life-saving. Alternatives to transfusions in the acute setting are few. However, for hemodynamically stable postoperative patients, hemoglobin concentrations of >7 g/dL are well tolerated [56]. An expanding body of evidence suggests that blood transfusion should be avoided, if possible. Blood transfusions have been associated with increased rates of nosocomial infection following penetrating abdominal trauma independent of related
New active device platforms for prevention of surgical site infection
Innovative technologies can be combined with established surgical practice to possibly decrease further the risk of SSI. Recognizing that two thirds of SSIs are superficial and stem from bacterial inoculation during surgery, and that interventions to decrease SSI after surgery have little impact, surgical device manufacturers are introducing new dual-action or “active platform” devices. Such devices may soon reduce incidence of SSI.
To reduce the infection rates associated with plastic surgery,
Summary
Promoting the healing process is an important consideration for both surgeons and patients. Certain timeless principles remain important, including preparation of the patient, careful adherence to sterile technique and infection control, judicious short-term use of antibiotics, and minimization of interventions that impair host defenses. Growth factors, silver hydrocolloid dressings, and the application of negative-pressure dressings can promote healing of chronic wounds, while suture
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