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S 1
urgical site infection (SSI) is defined as Identify high-risk patients early: The
infection of an operated site developing first important step in SSI prevention is
within 30 days after the operation, or within identification of patients deemed to be at high
1 year if an implant is present. SSIs are classified risk (National Institute for Health and Care
according to the affected tissue as superficial, Excellence, 2008). Current guidelines highlight
deep and organ/space infections (Anderson that risk is increased by:
Author: et al, 2014). ■■ Age (over 65 years)
Jan Stryja
SSIs are common complications in acute ■■ Underlying illness
healthcare facilities. They affect up to one-third ■■ Obesity (body mass index over 35 kg/m2)
of patients who have undergone a surgical ■■ Smoking.
procedure (World Health Organization [WHO}, ■■ Untreated peripheral vascular disease.
2016). They are the most surveyed and frequent ■■ Specific surgical procedures – site of the
type of healthcare-associated infection in operation (e.g. groin), longer duration of
low- and middle-income countries. In the US, surgery, extensive intra-operative techniques
approximately 160,000–300,000 SSIs occur and possible wound contamination.
each year. The incidence of SSIs worldwide is In the case of underlying illnesses, patients
debatable and underestimated; this is due to with an American Society of Anesthesiologists’ (ASA)
many factors, one of which is poor surveillance in physical status classification system score of III
community or primary care, and although there is or greater have statistically significantly higher
surveillance in the acute care setting, its accuracy SSI incidence (Box 1). The ASA’s classification of
is questionable. physical health is a widely used grading system
SSIs seriously impair not only the patient’s for preoperative health of the surgical patients;
quality of life, but also have a negative a subjective assessment of a patient’s overall
economical impact – they can double the length health is based on five classes (I to V). Specific
of a hospital stay. The additional costs of care for conditions contributing to a higher incidence of
an SSI are between £814 and £6,626, depending SSI include diabetes (two- to three-fold increase
on the type of surgery and the severity of the in risk), malnourishment (increased incidence
infection (Leaper et al, 2004; Kiernan and Leaper, of SSI from 1.8% to 16.6%), low serum albumin,
2014). It is estimated that up to 60% of SSIs are cancer therapy, radiotherapy (within 90 days prior
preventable (WHO, 2016). to surgery) and using systemic steroids.
SSIs are due to two main pathophysiologic
factors – organisms being introduced into the
wound directly from the patient (endogenous
contamination) or organisms originating from
2 Remove an individual’s risk factors
where possible: Do not underestimate
the importance of the patient’s preoperative
the outside environment relating to the length preparation. Elimination of risk factors such as
of the surgical procedure or break in asepsis malnutrition, smoking or medication is possible.
(exogenous contamination). Diminished efficacy It is worthwhile to try and address them before
of the general or local immune response of the scheduled surgery.
individual due to general (disease, malnutrition, Encourage patients to reduce weight and stop
medication) and local factors (perfusion, smoking. There is evidence that preoperative
bioburden, tissue damage) can result in increased smoking interventions providing behavioural
susceptibility to SSIs. support and offering nicotine replacement
These Ten Top Tips outline potential risks, therapy increase short-term smoking cessation
patient assessment, and preventative and and may reduce postoperative morbidity
management strategies. There is limited evidence (Thomsen et al, 2014). A review should be carried
for some of these tips, but the lack of strong out to identify medications which can be paused
evidence is more because of a lack of high-quality for the surgery and recovery period, e.g. consider
trials than anything else. a break in steroids or anticoagulants, if possible.
Jan Stryja is Vascular Surgeon and
What is clear is that there needs to be a focus
EWMA Council Member, Salvatella
Ltd, Czech Republic
on prevention and early detection because of the
clinical and economic impact of SSIs. 3 Achieve and maintain a sterile operating
site: SSI prevention is aimed at minimising
the number of microorganisms introduced into Box 1. ASA physical status classification system.
the operated site by removing microorganisms
The American Society of Anesthesiologists (ASA)
that normally colonise the skin (antiseptic physical status classification system:
skin preparation, preoperative soap or
antiseptic shower/bath), preventing access ASA I A normal healthy patient.
of microorganisms during operation from ASA II A patient with mild systemic disease.
the outside environment into the incision, ASA III A patient with severe systemic disease.
preventing the multiplication of microorganisms
ASA IV A patient with severe systemic disease
at the operative site (e.g. by using prophylactic
that is a constant threat to life.
systemic antibiotics), enhancing the patient’s
defences against infection (e.g. minimising ASA V A moribund patient who is not expected
to survive without the operation.
tissue damage and maintaining perioperative
normothermia) (Jones et al, 2014; Madrid ASA VI A declared brain-dead patient whose
et al, 2016). organs are being removed for donor
purposes.
The birth of an SSI depends on contamination
of the wound site at the end of a surgical
procedure. With respect to this, we distinguish the incidence of SSI compared with standard
endogenous and exogenous surgical dressings suggest that ciNPT is a potentially
site infections. effective method for reducing SSI and may
According to research, the presence of a be associated with a decreased incidence of
foreign body (implant, vascular graft after arterial dehiscence (Apelqvist et al, 2017).
bypass, pacemaker device, etc) reduces the A 2014 Cochrane review concluded that the
number of pathogenic organisms required to evidence for NPWT reducing SSIs and wound
cause an SSI (World Union of Wound Healing dehiscence remains unclear, as does the effect of
Societies, 2008). NPWT on time to complete healing (Webster et
al, 2014). To finally evaluate the effect of NPWT
9
Dumville JC, Gray TA, Walter CJ, et al (2016) Dressings
Diagnose SSIs early and look for typical for the prevention of surgical site infection. Cochrane
infection signs: The signs and symptoms Database Syst Rev 12: CD003091
of SSIs are defined by the European Wound Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, et al (2015)
Management Association (EWMA, 2005). These Hand washing promotion for preventing diarrhoea.
include: pus, abscess or purulent discharge Cochrane Database Syst Rev 9: CD004265
from the wound, local unexpected pain, European Wound Management Association (2005).
Position Document: Identifying criteria for wound
increase of local skin temperature, erythema infection. MEP, London
and swelling as a clinical manifestation of Gould DJ, Moralejo D,Drey N, et al (2017) Interventions
cellulitis. For high-risk patients, such as people to improve hand hygiene compliance in patient care.
with diabetes and the elderly, SSI signs do not Cochrane Database Syst Rev 9: CD005186
always appear in a typical way. Patients should Jones DJ, Bunn F, Bell-Syer SV (2014) Prophylactic
therefore be carefully examined during any antibiotics to prevent surgical site infection after
breast cancer surgery. Cochrane Database Syst Rev 3:
inspection of the wound. Early diagnosis of CD005360
infection allows clinicians to stop the spread Kiernan M, Leaper DJ (2014) Healthcare-associated
of microorganisms into adjacent tissues and to infections (HCAIs): The magnitude of the problem.
treat infection more efficiently. EWMA J 14(2): 35–7
Leaper DJ, van Goor H, Reilly J, et al (2004) Surgical site
London. Available at: https://www.nice.org.uk/cg74 grafts and surgical wounds healing by primary
(accessed 22.03.2018) intention. Cochrane Database Syst Rev 10: CD009261
Tanner J, Dumville JC, Norman G, Fortnam M (2016) World Health Organization (2016) Global Guidelines
Surgical hand antisepsis to reduce surgical site on the Prevention of Surgical Site Infection. WHO,
infection. Cochrane Database Syst Rev 1: CD004288 Geneva. Available at: http://bit.ly/2nsx6vu (accessed
Thomsen T, Villebro N, Møller AM (2014) Interventions 22.03.2018)
for preoperative smoking cessation. Cochrane World Union of Wound Healing Societies (2008)
Database Syst Rev 3: CD002294 Wound Infection in Clinical Practice. An International
Webster J, Scuffham P, Stankiewicz M, Chaboyer WP Consensus. MEP Ltd, London. Available at: https://bit.
(2014) Negative pressure wound therapy for skin ly/1ABVWpQ (accessed 11.04.2018)