1 PREVENTION OF POSTOPERATIVE
INFECTION
Jonathan L. Meakins, M.D., D.Sc., F.A.C.S., and Byron J. Masterson, M.D., F.A.C.S.
Historically, the control of wound infection depended on antiseptic and aseptic techniques directed at coping with the infecting
organism. In the 19th century and the early part of the 20th century, wound infections had devastating consequences and a measurable mortality. Even in the 1960s, before the correct use of
antibiotics and the advent of modern preoperative and postoperative care, as much as one quarter of a surgical ward might have
been occupied by patients with wound complications. As a result,
wound management, in itself, became an important component of
ward care and of medical education. It is fortunate that many factors have intervened so that the so-called wound rounds have
become a practice of the past. The epidemiology of wound infection has changed as surgeons have learned to control bacteria and
the inoculum as well as to focus increasingly on the patient (the
host) for measures that will continue to provide improved results.
The following three factors are the determinants of any infectious process:
1. The infecting organism (in surgical patients, usually bacteria).
2. The environment in which the infection takes place (the local
response).
3. The host defense mechanisms, which deal systemically with the
infectious process.1
Wounds are particularly appropriate for analysis of infection
with respect to these three determinants. Because many components of the bacterial contribution to wound infection now are
clearly understood and measures to control bacteria have been
implemented, the host factors become more apparent. In addition, interactions between the three determinants play a critical
role, and with limited exceptions (e.g., massive contamination),
few infections will be the result of only one factor [see Figure 1].
Standardization in reporting will permit more effective surveillance and improve results, as well as offer a painless way of
achieving quality assurance.The natural tendency to deny that a
surgical site has become infected contributes to the difficulty of
defining SSI in a way that is both accurate and acceptable to surgeons. The surgical view of SSI recalls one judges (probably
apocryphal) remark about pornography: It is hard to define, but
I know it when I see it. SSIs are usually easy to identify.
Nevertheless, there is a critical need for definitions of SSI that
can be applied in different institutions for use as performance
indicators.4 The criteria on which such definitions must be based
are more detailed than the simple apocryphal remark just cited;
they are outlined more fully elsewhere [see 1:8 Preparation of the
Operating Room].
STRATIFICATION OF RISK FOR SSI
Wound infections have traditionally been thought of as infections in a surgical wound occurring between the skin and the deep
soft tissuesa view that fails to consider the operative site as a
whole. As prevention of these wound infections has become more
effective, it has become apparent that definitions of operationrelated infection must take the entire operative field into account;
obvious examples include sternal and mediastinal infections, vascular graft infections, and infections associated with implants (if
occurring within 1 year of the procedure and apparently related to
it). Accordingly, the Centers for Disease Control and Prevention
currently prefers to use the term surgical site infection (SSI). SSIs
can be classified into three categories: superficial incisional SSIs
(involving only skin and subcutaneous tissue), deep incisional
SSIs (involving deep soft tissue), and organ/space SSIs (involving
anatomic areas other than the incision itself that are opened or
manipulated in the course of the procedure) [see Figure 2].2,3
BACTERIA
HOST
DEFENSE
MECHANISMS
SURGICAL
SITE
Endogenous factors
or sources of bacteria
Remote sites of
infection
Postpone elective
operation if possible.
Treat remote infection
appropriately.
Skin
Bowel
Size of
inoculum
required to
produce
infection
Varies in
different
clinical
situations.
Exogenous factors
or sources of bacteria
Operating
teamrelated
Operating
roomrelated
Comportment
Use of
impermeable
drapes and
gowns
Surgical scrub
Traffic control
Cleaning
Air
BACTERIA
HOST
DEFENSE
MECHANISMS
Factors contributing to dysfunction of host defense mechanisms
can be related to surgical disease, to events surrounding the operation,
to the patients underlying disease, and to anesthetic management.
SURGICAL
SITE
Surgeon-related
Patient-related
Anesthesiologist-related
Patient-related factors
include
Presence of 3
concomitant diagnoses
Underlying disease
Age
Drug use
Preoperative nutritional
status
Smoking
Operating teamrelated
factors
Patient-related
include
Patient-related
Age
PaO2
Abdominal procedure
Tissue perfusion
Presence of foreign body
Barrier function
Diabetes
Normothermia
Normovolemia
Pain control
Tissue oxygenation
Glucose control
Sterility of drugs
CONTROL OF SOURCES OF
BACTERIA
Skin
Subcutaneous
Tissue
Organ/Space
Superficial
Incisional
SSI
Deep Incisional
SSI
Organ/Space
SSI
Figure 2 Surgical site infections are classified into three categories, depending on which anatomic areas are affected.3
Bacteria
Clearly, without an
infecting agent, no infection
will result. Accordingly,
most of what is known
about bacteria is put to use
in major efforts directed at
reducing their numbers by means of asepsis and antisepsis. The
principal concept is based on the size of the bacterial inoculum.
Wounds are traditionally classified according to whether the
wound inoculum of bacteria is likely to be large enough to overwhelm local and systemic host defense mechanisms and produce
an infection [see Table 1]. One study showed that the most important factor in the development of a wound infection was the number of bacteria present in the wound at the end of an operative
procedure.10 Another study quantitated this relation and provided
insight into how local environmental factors might be integrated
into an understanding of the problem [see Figure 3].11 In the years
before prophylactic antibiotics, as well as during the early phases
of their use, there was a very clear relation between the classification of the operation (which is related to the probability of a significant inoculum) and the rate of wound infection.5,12 This relation is now less dominant than it once was; therefore, other factors have come to play a significant role.6,13
Clean (class I)
Nontraumatic
No inflammation encountered
No break in technique
Respiratory, alimentary, or genitourinary tract not
entered
Cleancontaminated
(class II)
Contaminated
(class III)
50
40
30
20
10
0
0
nation have been proposed frequently. These techniques, particularly preoperative skin decontamination [see Sidebar Preoperative
Preparation of the Operative Site], may have specific roles in
selected patients during epidemics or in units with high infection
rates. As a routine for all patients, however, these techniques are
unnecessary, time-consuming, and costly in institutions or units
where infection rates are low.
The preoperative shave is a technique in need of reassessment.
It is now clear that shaving the evening before an operation is associated with an increased wound infection rate.This increase is sec-
ondary to the trauma of the shave and the inevitable small areas of
inflammation and infection. If hair removal is required,14,15 clipping is preferable and should be done in the OR or the preparation room just before the operative procedure. Shaving, if ever performed, should not be done the night before operation.
In the past few years, the role of the classic bowel preparation [see
Table 5] has been questioned [see Discussion, Infection Prevention
in Bowel Surgery, below].16-20 The suggestion has been made that
selective gut decontamination (SGD) may be useful in major elective procedures involving the upper GI tract and perhaps in other
settings. At present, SGD for prevention of infection cannot be recommended in either the preoperative or the postoperative period.
When infection develops after clean operations, particularly
those in which foreign bodies were implanted, endogenous infecting organisms are involved but the skin is the primary source of the
infecting bacteria. The air in the operating room and other OR
sources occasionally become significant in clean cases; the degree
of endogenous contamination can be surpassed by that of exogenous contamination. Thus, both the operating teamsurgeon,
assistants, nurses, and anesthetistsand OR air have been reported as significant sources of bacteria [see 1:8 Preparation of the
Operating Room]. In fact, personnel are the most important source
of exogenous bacteria.21-23 In the classic 1964 study by the National
Academy of SciencesNational Research Council, ultraviolet light
(UVL) was efficacious only in the limited situations of clean and
ultraclean cases.5 There were minimal numbers of endogenous
bacteria, and UVL controlled one of the exogenous sources.
Clean air systems have very strong advocates, but they also have
equally vociferous critics. It is possible to obtain excellent results
in clean cases with implants without using these systems.
However, clean air systems are here to stay. Nevertheless, the presence of a clean air system does not mean that basic principles of
asepsis and antisepsis should be abandoned, because endogenous
bacteria must still be controlled.
The use of impermeable drapes and gowns has received considerable attention. If bacteria can penetrate gown and drapes,
they can gain access to the wound.The use of impermeable drapes
may therefore be of clinical importance.24,25 When wet, drapes of
140-thread-count cotton are permeable to bacteria. It is clear that
some operations are wetter than others, but generally, much can
be done to make drapes and gowns impermeable to bacteria. For
example, drapes of 270-thread-count cotton that have been water-
Dose
Route of
Administration
Cefazolin
1g
Vancomycin
1g
I.V. or I.M.
(I.V. preferred)
I.V.
600 mg
I.V.
500 mg
I.V.
1.5 mg/kg
I.V. or I.M.
(I.V. preferred
for first dose)
12 g
12 g
I.V.
I.V.
Clindamycin
or
Metronidazole
plus
Tobramycin
(or equivalent
aminoglycoside)
Cefoxitin
Cefotetan
Abdominal procedures. In biliary tract procedures (open or laparoscopic), prophylaxis is required only for patients at high risk: those
whose common bile duct is likely to be explored (because of jaundice,
bile duct obstruction, stones in the common bile duct, or a reoperative
biliary procedure); those with acute cholecystitis; and those older than
70 years. A single dose of cefazolin is adequate. In hepatobiliary and
pancreatic procedures, antibiotic prophylaxis is always warranted because these operations are clean-contaminated, because they are long,
because they are abdominal, or for all of these reasons. Prophylaxis is
also warranted for therapeutic endoscopic retrograde cholangiopancreatography. In gastroduodenal procedures, patients whose gastric acidity is normal or high and in whom bleeding, cancer, gastric ulcer, and obstruction are absent are at low risk for infection and require no
prophylaxis; all other patients are at high risk and require prophylaxis.
Patients undergoing operation for morbid obesity should receive double
the usual prophylactic dose110; cefazolin is an effective agent.
Operations on the head and neck (including the esophagus). Patients whose operation is of significance (i.e., involve entry into the oral
cavity, the pharynx, or the esophagus) require prophylaxis.
Gynecologic procedures. Patients whose operation is either highrisk cesarean section, abortion, or vaginal or abdominal hysterectomy
will benefit from cefazolin. Aqueous penicillin G or doxycycline may be
preferable for first-trimester abortions in patients with a history of pelvic
inflammatory disease. In patients with cephalosporin allergy, doxycycline is effective for those having hysterectomies and metronidazole for
those having cesarean sections. Women delivering by cesarean section should be given the antibiotic immediately after cord clamping.
Urologic procedures. In principle, antibiotics are not required in patients with sterile urine. Patients with positive cultures should be treated. If an operative procedure is performed, a single dose of the appropriate antibiotic will suffice.
(continued )
Infected cases require therapeutic courses of antibiotics; prophylaxis is not appropriate in this context. In dirty cases, particularly those re-
BACTERIAL PROPERTIES
Table 4
Manipulative Procedure
Usual
Oral
Amoxicillin, 2.0 g 1 hr before procedure
Oral
Clindamycin, 600 mg 1 hr before procedure
or
Cephalexin or cefadroxil, 2.0 g 1 hr before procedure
or
Azithromycin or clarithromycin, 500 mg 1 hr before procedure
Parenteral
Ampicillin, 2.0 g I.M. or I.V. 30 min before procedure
Parenteral
Clindamycin, 600 mg I.V. within 30 min before procedure
or
Cefazolin, 1.0 g I.M. or I.V. within 30 min before procedure
Oral
Amoxicillin, 2.0 g 1 hr before procedure
Gastrointestinal or genitourinary
operation; abscess drainage
Parenteral
Ampicillin, 2.0 g I.M. or I.V. within 30 min before procedure; if risk of endocarditis is considered high, add
gentamicin, 1.5 mg/kg (to maximum of 120 mg) I.M.
or I.V. 30 min before procedure
*Pediatric dosages are as follows: oral amoxicillin, 50 mg/kg; oral or parenteral clindamycin, 20 mg/kg; oral cephalexin or cefadroxil, 50 mg/kg; oral azithromycin or clarithromycin, 15 mg/kg;
parenteral ampicillin, 50 mg/kg; parenteral cefazolin, 25 mg/kg; parenteral gentamicin, 2 mg/kg; parenteral vancomycin, 20 mg/kg. Total pediatric dose should not exceed total adult dose.
Patients with a history of immediate-type sensitivity to penicillin should not receive these agents.
High-risk patients should also receive ampicillin, 1.0 g I.M. or I.V., or amoxicillin, 1.0 g p.o., 6 hr after procedure.
Duration of Operation
In most studies,6,10,12 contamination certainly increases with
time (see above).Wound edges can dry out, become macerated, or
in other ways be made more susceptible to infection (i.e., requiring fewer bacteria for development of infection). Speed and poor
technique are not suitable approaches; expeditious operation is
appropriate.
Electrocautery
The use of electrocautery devices has been clearly associated
with an increase in the incidence of superficial SSIs. However,
when such devices are properly used to provide pinpoint coagulation (for which the bleeding vessels are best held by fine forceps) or to divide tissues under tension, there is minimal tissue
destruction, no charring, and no change in the wound infection
rate.30
PATIENT FACTORS
Host Defense
Mechanisms
Period 2*
Hospital A
Number of wounds
Wound infection rate
1,500
8.4%
1,447
3.7%
Hospital B
Number of wounds
Wound infection rate
1,746
5.7%
1,939
3.7%
*Periods 1 and 2 were separated by an interval during which feedback on wound infection
rates was analyzed.
No Antibiotic
Antibiotic
100
80
60
40
20
0
Control
1 Hr
Day 1
Control
1 Hr
Day 1
Time of Inoculation
108
Bacteria/ml
107 Bacteria/ml
106 Bacteria/ml
Bacteria
ANESTHESIOLOGISTRELATED FACTORS
A 2000 commentary in
The Lancet by Donal Buggy
considered the question of
whether anesthetic management could influence surgical wound healing.44 In
addition to the surgeon- and patient-related factors already discussed (see above), Buggy cogently identified a number of anesthesiologist-related factors that could contribute to better wound
healing and reduced wound infection. Some of these factors (e.g.,
pain control, epidural anesthesia, and autologous transfusion) are
unproven but nonetheless make sense and should certainly be tested. Others (e.g., tissue perfusion, intravascular volume, andsignificantlymaintenance of normal perioperative body temperature) have undergone formal evaluation. Very good studies have
shown that dramatic reductions in SSI rates can be achieved
through careful avoidance of hypothermia.40,45 Patient-controlled
analgesia pumps are known to be associated with increased SSI
rates, through a mechanism that is currently unknown.46 Infection
control practices are required of all practitioners; contamination of
anesthetic drugs by bacteria has resulted in numerous small outbreaks of SSI.47,48
As modern surgical practice has evolved and the variable of bac-
Wound
Environment
(Local Factors)
Host Defense
Mechanisms
(Systemic Factors)
B
B
B
C
C
C
C
C
A
A
A
A
A
B
B
B
B
C
C
C
C
Discussion
Antibiotic Prophylaxis of Surgical Site Infection
It is difficult to understand why antibiotics have not always prevented SSI successfully. Certainly, surgeons were quick to appreciate the possibilities of antibiotics; nevertheless, the efficacy of
antibiotic prophylaxis was not proved until the late 1960s.11
Studies before then had major design flawsprincipally, the
administration of the antibiotic some time after the start of the
operation, often in the recovery room. The failure of studies to
demonstrate efficacy and the occasional finding that prophylactic
antibiotics worsened rather than improved outcome led in the late
Staphylococcal Lesions
10
use, anesthesia, and surveillance have reduced SSI rates in all categories that were established by this classification [see Table
8].6,12,13,51
In 1960, after years of negative studies, it was said, Nearly all
surgeons now agree that the routine use of prophylaxis in clean
operations is unnecessary and undesirable.57 Since then, much
has changed: there are now many clean operations for which no
competent surgeon would omit the use of prophylactic antibiotics,
particularly as procedures become increasingly complex and prosthetic materials are used in patients who are older, sicker, or
immunocompromised.
A separate risk assessment that integrates host and bacterial
variables (i.e., whether the operation is dirty or contaminated, is
longer than 2 hours, or is an abdominal procedure and whether the
patient has three or more concomitant diagnoses) segregates more
effectively those patients who are prone to an increased incidence
of SSI [see Integration of Determinants of Infection, below]. This
approach enables the surgeon to identify those patients who are
likely to require preventive measures, particularly in clean cases, in
which antibiotics would normally not be used.6
The prototypical clean operation is an inguinal hernia repair.
Technical approaches have changed dramatically over the past 10
years, and most primary and recurrent hernias are now treated
with a tension-free mesh-based repair. The use of antibiotics has
become controversial. In the era of repairs under tension, there was
some evidence to suggest that a perioperative antibiotic (in a single preoperative dose) was beneficial.58 Current studies, however,
do not support antibiotic use in tension-free mesh-based inguinal
hernia repairs.59,60 On the other hand, if surveillance indicates that
there is a local or regional problem61 with SSI after hernia surgery,
antibiotic prophylaxis (again in the form of single preoperative
dose) is appropriate. Without significantly more supportive data,
prophylaxis for clean cases cannot be recommended unless specific risk factors are present.
Data suggest that prophylactic use of antibiotics may contribute
to secondary Clostridium difficile disease; accordingly, caution
should be exercised when widening the indications for prophylaxis is under consideration.62 If local results are poor, surgical practice should be reassessed before antibiotics are prescribed.
ANTIBIOTIC SELECTION AND ADMINISTRATION
Table 8
Wound
Classification
Clean
Clean-contaminated
Contaminated
Dirty-infected
Overall
51
12
19601962
(15,613 patients)
19671977
(62,937 patients)
197519766
(59,353 patients)
1977198113
(20,193 patients)
19821986107
(20,703 patients)
5.1
10.8
16.3
28.0
1.5
7.7
15.2
40.0
2.9
3.9
8.5
12.6
1.8
2.9
9.9
1.3
2.5
7.1
7.4
4.7
4.1
2.8
2.2
can clearly be reduced by this regimen. No data suggest that further doses are required for prophylaxis.
Fortunately, cefazolin is effective against both gram-positive
and gram-negative bacteria of importance, unless significant
anaerobic organisms are encountered.The significance of anaerobic flora has been disputed, but for elective colorectal surgery,65
abdominal trauma,66,67 appendicitis,68 or other circumstances in
which penicillin-resistant anaerobic bacteria are likely to be
encountered, coverage against both aerobic and anaerobic gramnegative organisms is strongly recommended and supported by
the data.
Despite several decades of studies, prophylaxis is not always
properly implemented.52,54,68,69 Unfortunately, didactic education
is not always the best way to change behavior. Preprinted order
forms70 and a reminder sticker from the pharmacy71 have proved
to be effective methods of ensuring correct utilization.
The commonly heard decision This case was tough, lets give
an antibiotic for 3 to 5 days has no data to support it and should
be abandoned. Differentiation between prophylaxis and therapeusis is important. A therapeutic course for perforated diverticulitis
or other types of peritoneal infection is appropriate. Data on casual contamination associated with trauma or with operative procedures suggest that 24 hours of prophylaxis or less is quite adequate.72-74 Mounting evidence suggests that a single preoperative
dose is good care and that additional doses are not required.
Trauma Patients
The efficacy of antibiotic administration on arrival in the emergency department as an integral part of resuscitation has been
clearly demonstrated.66 The most common regimens have been
(1) a combination of an aminoglycoside and clindamycin and (2)
cefoxitin alone. These two regimens or variations thereof have
been compared in a number of studies.40,67,75 They appear to be
equally effective, and either regimen can be recommended with
confidence. For prophylaxis, there appears to be a trend toward
using a single drug: cefoxitin or cefotetan.55 If therapy is required
because of either a delay in surgery, terrible injury, or prolonged
shock, the combination of an agent that is effective against anaerobes with an aminoglycoside seems to be favored. Because aminoglycosides are nephrotoxic, they must be used with care in the
presence of shock.
In many of the trauma studies just cited, antibiotic prophylaxis
lasted for 48 hours or longer. Subsequent studies, however, indicated that prophylaxis lasting less than 24 hours is appropriate.73,74,76 Single-dose prophylaxis is appropriate for patients with
closed fractures.77
COMPLICATIONS
Hand Washing
Table 9
Agent
Antifungal
Activity
Chlorhexidine
Fair
Iodine/iodophors
Good
Alcohols
Denaturation of protein
Good
Comments
Poor activity against tuberculosis-causing organisms; can
cause ototoxicity and eye irritation
Broad antibacterial spectrum; minimal skin residual activity; possible absorption toxicity and skin irritation
Rapid action but little residual activity; flammable
Low
Risk
Medium
Risk
Clean
1.1
3.9
8.4
15.8
2.9
Clean-contaminated
0.6
2.8
8.4
17.7
3.9
Contaminated
4.5
8.3
11.0
23.9
8.5
Dirty-infected
6.7
10.9
18.8
27.4
12.6
3.6
8.9
17.2
27.0
4.1
1.0
High
Risk
4
All from
Traditional
Classification
The significant advances in the control of wound infection during the past several decades are linked to a better understanding of
the biology of wound infection, and this link has permitted the
advance to the concept of SSI.2 In all tissues at any time, there will
be a critical inoculum of bacteria that would cause an infectious
process [see Figure 3].The standard definition of infection in urine
and sputum has been 105 organisms/ml. In a clean dry wound, 105
bacteria produce a wound infection rate of 50% [see Figure 3].11
Effective use of antibiotics reduces the infection rate to 10% with
the same number of bacteria and thereby permits the wound to
tolerate a much larger number of bacteria.
All of the clinical activities described are intended either to
reduce the inoculum or to permit the host to manage the number
of bacteria that would otherwise be pathologic. One study in
guinea pigs showed how manipulation of local blood flow, shock,
the local immune response, and foreign material can enhance the
development of infection.99 This study and two others defined an
early decisive period of host antimicrobial activity that lasts for 3
to 6 hours after contamination.50,99,100 Bacteria that remain after
this period are the infecting inoculum. Processes that interfere
with this early response (e.g., shock, altered perfusion, adjuvants,
or foreign material) or support it (e.g., antibiotics or total care)
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Acknowledgment
Figures 3 and 4
Albert Miller.