Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-24T22:39:48.225Z Has data issue: false hasContentIssue false
  • English
  • Français

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals

Published online by Cambridge University Press:  02 January 2015

Deverick J. Anderson ,
Keith S. Kaye ,
David Classen ,
Kathleen M. Arias ,
Kelly Podgorny ,
Helen Burstin ,
David P. Calfee ,
Susan E. Coffin ,
Erik R. Dubberke  and
Victoria Fraser
...Show all authors
Deverick J. Anderson
Affiliation:
Duke University Medical Center, Durham, North Carolina
Keith S. Kaye
Affiliation:
Duke University Medical Center, Durham, North Carolina
David Classen
Affiliation:
University of Utah, Salt Lake City
Kathleen M. Arias
Affiliation:
Association for Professionals in Infection Control and Epidemiology, Washington, D.C.
Kelly Podgorny
Affiliation:
Joint Commission, Oakbrook Terrace, Chicago
Helen Burstin
Affiliation:
National Quality Forum, Washington, D.C.
David P. Calfee
Affiliation:
Mount Sinai School of Medicine, New York, New York
Susan E. Coffin
Affiliation:
Children's Hospital of Philadelphiaand University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Erik R. Dubberke
Affiliation:
Washington University School of Medicine, St. Louis, Missouri
Victoria Fraser
Affiliation:
Washington University School of Medicine, St. Louis, Missouri
Dale N. Gerding
Affiliation:
Loyola University Chicago Stritch School of Medicine, Chicago Hines Veterans Affairs Medical Center, Hines, Illinois
Frances A. Griffin
Affiliation:
Institute for Healthcare Improvement, Cambridge
Peter Gross
Affiliation:
Hackensack University Medical Center, Hackensack, New Jersey University of Medicine and Dentistry–New Jersey Medical School, Newark, New Jersey
Michael Klompas
Affiliation:
Brigham and Women's Hospitaland Harvard Medical School, Boston, Massachusetts
Evelyn Lo
Affiliation:
University of Manitoba, Winnipeg, Canada
Jonas Marschall
Affiliation:
Washington University School of Medicine, St. Louis, Missouri
Leonard A. Mermel
Affiliation:
Warren Alpert Medical School of Brown Universityand Rhode Island Hospital, Providence, Rhode Island
Lindsay Nicolle
Affiliation:
University of Manitoba, Winnipeg, Canada
David A. Pegues
Affiliation:
David Geffen School of Medicine at the University of California, Los Angeles
Trish M. Perl
Affiliation:
Johns Hopkins Medical Institutions and University, Baltimore, Maryland
Sanjay Saint
Affiliation:
Ann Arbor Veterans Affairs Medical Center and theUniversity of Michigan Medical School, Ann Arbor, Michigan
Cassandra D. Salgado
Affiliation:
Medical University of South Carolina, Charleston
Robert A. Weinstein
Affiliation:
Stroger (Cook County) Hospital andRush University Medical Center, Chicago
Robert Wise
Affiliation:
Joint Commission, Oakbrook Terrace, Chicago
Deborah S. Yokoe
Affiliation:
Brigham and Women's Hospitaland Harvard Medical School, Boston, Massachusetts
Get access Rights & Permissions [Opens in a new window]

Extract

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Burden of SSIs as complications in acute care facilities.

a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.

b. Approximately 500,000 SSIs occur each year.

2. Outcomes associated with SSI

a. Each SSI is associated with approximately 7-10 additional postoperative hospital days.

b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.

i. Seventy-seven percent of deaths among patients with SSI are direcdy attributable to SSI.

c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from $3,000 to $29,000.

i. SSIs are believed to account for up to $10 billion annually in healthcare expenditures.

1. Definitions

a. The Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System and the National Healthcare Safety Network definitions for SSI are widely used.

b. SSIs are classified as follows (Figure):

i. Superficial incisional (involving only skin or subcutaneous tissue of the incision)

ii. Deep incisional (involving fascia and/or muscular layers)

iii. Organ/space

Type
SHEA/IDSA Practice Recommendations
Information
Infection Control & Hospital Epidemiology , Volume 29 , supplement S1: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals , October 2008 , pp. S51 - S61
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Cruse, P. Wound infection surveillance. Rev Infect Dis 1981;3:734–737.Google Scholar
2.Cruse, PJ, Foord, R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27–40.CrossRefGoogle Scholar
3.Engemann, JJ, Carmeli, Y, Cosgrove, SE, et al.Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592–598.Google Scholar
4.Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725–730.CrossRefGoogle ScholarPubMed
5.Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–278; quiz 279-280.CrossRefGoogle ScholarPubMed
6.Coello, R, Glenister, H, Fereres, J, et al.The cost of infection in surgical patients: a case-control study. J Hosp Infect 1993;25:239–250.Google Scholar
7.Boyce, JM, Potter-Bynoe, G, Dziobek, L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1990;11:89–93.Google Scholar
8.Vegas, AA, Jodra, VM, Garcia, ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol 1993;9:504–510.Google Scholar
9.VandenBergh, MF, Kluytmans, JA, van Hout, BA, et al.Cost-effectiveness of perioperative mupirocin nasal ointment in cardiothoracic surgery. Infect Control Hosp Epidemiol 1996;17:786–792.CrossRefGoogle ScholarPubMed
10.Hollenbeak, CS, Murphy, DM, Koenig, S, Woodward, RS, Dunagan, WC, Fraser, VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000;118:397–402.CrossRefGoogle ScholarPubMed
11.Whitehouse, JD, Friedman, ND, Kirkland, KB, Richardson, WJ, Sexton, DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002;23:183–189.Google Scholar
12.Apisarnthanarak, A, Jones, M, Waterman, BM, Carroll, CM, Bernardi, R, Fraser, VJ. Risk factors for spinal surgical-site infections in a community hospital: a case-control study. Infect Control Hosp Epidemiol 2003;24:31–36.CrossRefGoogle Scholar
13.Wong, ES. Surgical site infections. In: Mayhall, CG, ed. Hospital Epidemiology and Infection Control. 3rd ed. Baltimore: Lippincott, Williams, and Wilkins; 2004:287–310.Google Scholar
14.Horan, TC, Gaynes, RP, Martone, WJ, Jarvis, WR, Emori, TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–608.CrossRefGoogle ScholarPubMed
15. National Healthcare Safety Network (NHSN) members page. Available at: http://www.cdc.gov/ncidod/dhqp/nhsn_members.html. Accessed August 5, 2008.Google Scholar
16.Condon, RE, Schulte, WJ, Malangoni, MA, Anderson-Teschendorf, MJ. Effectiveness of a surgical wound surveillance program. Arch Surg 1983;118:303–307.CrossRefGoogle ScholarPubMed
17.Kerstein, M, Flower, M, Harkavy, LM, Gross, PA. Surveillance for post-operative wound infections: practical aspects. Am Surg 1978;44:210–214.Google Scholar
18.Mead, PB, Pories, SE, Hall, P, Vacek, PM, Davis, JH JrGamelli, RL. Decreasing the incidence of surgical wound infections: validation of a surveillance-notification program. Arch Surg 1986;121:458–461.Google Scholar
19.Baker, C, Luce, J, Chenoweth, C, Friedman, C. Comparison of case-finding methodologies for endometritis after cesarean section. Am J Infect Control 1995;23:27–33.CrossRefGoogle ScholarPubMed
20.Cardo, DM, Falk, PS, Mayhall, CG. Validation of surgical wound surveillance. Infect Control Hosp Epidemiol 1993;14:211–215.CrossRefGoogle ScholarPubMed
21.Chalfine, A, Cauet, D, Lin, WC, et al.Highly sensitive and efficient computer-assisted system for routine surveillance for surgical site infection. Infect Control Hosp Epidemiol 2006;27:794–801.Google Scholar
22.Miner, AL, Sands, KE, Yokoe, DS, et al.Enhanced identification of post-operative infections among outpatients. Emerg Infect Dis 2004;10:1931–1937.CrossRefGoogle Scholar
23.Yokoe, DS, Noskin, GA, Cunnigham, SM, et al.Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2004;10:1924–1930.Google Scholar
24.Burke, JP. Infection control—a problem for patient safety. N Engl J Med 2003;348:651–656.Google Scholar
25.Sands, K, Vineyard, G, Platt, R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996;173:963–970.Google Scholar
26.Mannien, J, Wille, JC, Snoeren, RL, van den Hof, S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands. Infect Control Hosp Epidemiol 2006;27:809–816.CrossRefGoogle Scholar
27.Culver, DH, Horan, TC, Gaynes, RP, et al.Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991;91:152S–157S.CrossRefGoogle ScholarPubMed
28.Pessaux, P, Msika, S, Atalla, D, Hay, JM, Flamant, Y. Risk factors for post-operative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg 2003;138:314–324.Google Scholar
29.Raymond, DP, Pelletier, SJ, Crabtree, TD, Schulman, AM, Pruett, TL, Sawyer, RG. Surgical infection and the aging population. Am Surg 2001;67:827–832; discussion 832-833.Google Scholar
30.Kaye, KS, Schmit, K, Pieper, C, et al.The effect of increasing age on the risk of surgical site infection. J Infect Dis 2005;191:1056–1062.CrossRefGoogle ScholarPubMed
31.Dronge, AS, Perkal, MF, Kancir, S, Concato, J, Asian, M, Rosenthal, RA. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006;141:375–380; discussion 380.CrossRefGoogle ScholarPubMed
32.Forse, RA, Karam, B, MacLean, LD, Christou, NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750–756; discussion 756-757.Google ScholarPubMed
33.Bratzler, DW, Houck, PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706–1715.Google Scholar
34.Haley, RW, Culver, DH, Morgan, WM, White, JW, Emori, TG, Hooton, TM. Identifying patients at high risk of surgical wound infection: a simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol 1985;121:206–215.Google Scholar
35.Bratzler, DW, Hunt, DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006;43:322–330.Google Scholar
36.Dellinger, EP, Hausmann, SM, Bratzler, DW, et al.Hospitals collaborate to decrease surgical site infections. Am J Surg 2005;190:9–15.Google Scholar
37. Institute for Healthcare Improvement. Available at: http://www.ihi.org/. Accessed May 1, 2007.Google Scholar
38.Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program—HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule. Fed Regist 2006;71:67959–68401.Google Scholar
39.van Kasteren, ME, Mannien, J, Kullberg, BJ, et al.Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. J Antimicrob Chemother 2005;56:1094–1102.CrossRefGoogle ScholarPubMed
40.Schweon, S. Stamping out surgical site infections. RN 2006;69:36–40; quiz 41.Google ScholarPubMed
41.Torpy, JM, Burke, A, Glass, RM. JAMA patient page: woun d infections. JAMA 2005;294:2122.Google Scholar
42.Pestotnik, SL, Classen, DC, Evans, RS, Burke, JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996;124:884–890.CrossRefGoogle ScholarPubMed
43.Kanter, G, Connelly, NR, Fitzgerald, J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg 2006;103:1517–1521.Google Scholar
44.Webb, AL, Flagg, RL, Fink, AS. Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration. Am J Surg 2006;192:663–668.CrossRefGoogle ScholarPubMed
45.Berger, RG, Kichak, JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004;11:100–103.Google Scholar
46.Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979;121:1193–1254.Google Scholar
47.Lee, JT. Wound infection surveillance. Infect Dis Clin North Am 1992;6:643–656.CrossRefGoogle ScholarPubMed
48.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 Epidemiol 1985;121:182–205.CrossRefGoogle ScholarPubMed
49.ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999;56:1839–1888.CrossRefGoogle Scholar
50.Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther 2001;43:92–97.Google Scholar
51.Gandhi, GY, Nuttall, GA, Abel, MD, et al.Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med 2007;146:233–243.CrossRefGoogle ScholarPubMed
52.Dodds Ashley, ES, Carroll, DN, Engemann, JJ, et al.Risk factors for post-operative mediastinitis due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2004;38:1555–1560.CrossRefGoogle ScholarPubMed
53.Bolon, MK, Morlote, M, Weber, SG, Koplan, B, Carmeli, Y, Wright, SB. Glycopeptides are no mor e effective than β-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis 2004;38:1357–1363.CrossRefGoogle Scholar
54.Brennan, MF, Pisters, PW, Posner, M, Quesada, O, Shike, M. A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994;220:436–441; discussion 441-444.CrossRefGoogle ScholarPubMed
55.Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 1991;325:525–532.Google Scholar
56.Kaul, AF, Jewett, JF. Agents and techniques for disinfection of the skin. Surg Gynecol Obstet 1981;152:677–685.Google ScholarPubMed
57.Webster, J, Osborne, S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2007;(2):CD004985.CrossRefGoogle ScholarPubMed
58.Perl, TM, Cullen, JJ, Wenzel, RP, et al.Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871–1877.CrossRefGoogle ScholarPubMed
59.Miller, MA, Dascal, A, Portnoy, J, Mendelson, J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after wide-spread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811–813.Google Scholar
60.Kallen, AJ, Wilson, CT, Larson, RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol 2005;26:916–922.Google Scholar
61.Wilcox, MH, Hall, J, Pike, H, et al.Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect 2003;54:196–201.CrossRefGoogle ScholarPubMed
62.Nicholson, MR, Huesman, LA. Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients. Am J Infect Control 2006;34:44–48.CrossRefGoogle ScholarPubMed
63.McKibben, L, Horan, T, Tokars, JI, et al.Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control 2005;33:217–226.CrossRefGoogle ScholarPubMed
64.Belda, FJ, Aguilera, L, Garcia de la Asuncion, J, et al.Supplemental perioperative oxygen and the risk of surgical woun d infection: a randomized controlled trial. JAMA 2005;294:2035–2042.CrossRefGoogle Scholar
65.Greif, R, Akca, O, Horn, EP, Kurz, A, Sessler, DI. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000;342:161–167.Google Scholar
66.Pryor, KO, Fahey, TJ 3rdLien, CA, Goldstein, PA. Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial. JAMA 2004;291:79–87.Google Scholar
67.Dellinger, EP. Increasing inspired oxygen to decrease surgical site infection: time to shift the quality improvement research paradigm. JAMA 2005;294:2091–2092.CrossRefGoogle ScholarPubMed
68.Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996;334:1209–1215.CrossRefGoogle ScholarPubMed
69.Barone, JE, Tucker, JB, Cecere, J, et al.Hypothermia does not result in more complications after colon surgery. Am Surg 1999;65:356–359.Google Scholar
70.Segers, P, Speekenbrink, RG, Ubbink, DT, van Ogtrop, ML, de Mol, BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006;296:2460–2466.CrossRefGoogle ScholarPubMed
71.Gaynes, RP, Culver, DH, Horan, TC, Edwards, JR, Richards, C, Tolson, JS. Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis 2001;33(Suppl 2):S69–S77.CrossRefGoogle ScholarPubMed
72.Gaynes, RP, Solomon, S. Improving hospital-acquired infection rates: the CDC experience. Jt Comm J Qual Improv 1996;22:457–467.Google ScholarPubMed
73.The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:599–605.Google Scholar
74.Wong, ES, Rupp, ME, Mermel, L, et al.Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005;26:210–212.CrossRefGoogle ScholarPubMed
75.McKibben, L, Horan, TC, Tokars, JI, et al.Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005;26:580–587.CrossRefGoogle ScholarPubMed
76. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007.Google Scholar
77.The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum.org/pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.Google Scholar