Surgical Site Infections

Despite every precautionary measure available to avoid complications from surgery, there are no guarantees when it comes to outcomes.

No matter how straightforward the surgical procedure to be performed, there are always inherent risks that must be considered, with the potential for infection always a concern. Prior to any surgery, consent of the patient must be obtained (whether directly or through the consent of a designated legal representative if the patient is not cognizant). It is the obligation of the surgeon to verbally explain that the potential for complications exists, and the informed consent that both parties sign provides further written indication that among such complications, infection may occur post-operatively.

The skin is our primary physical barrier to prevent pathogens from entering our bodies. Any compromise or break in the skin may create a portal of entry for invading organisms and the potential for infection ranging from minor to life threatening. Pre-, intra- and post-operative protocols are extensive and highly effective in preventing such infections and reported rates of surgical site infections are estimated at 1-3%. However, any procedure that causes a break in the skin represents a potential source of infection.

According to the Alliance of Wound Care Stakeholders, chronic wounds impact nearly 15% of Medicare beneficiaries. The costs associated with wounds is conservatively estimated at nearly $32 billion annually in the United States, with surgical infections as the highest prevalence category, followed by diabetic foot infections. Surgical wounds and diabetic foot ulcers drove the highest total wound care costs (including cost of infections).2

CAUSES OF SURGICAL SITE INFECTION

Surgical site infections are caused by pathogens that are typically bacterial. The most common of these include Staphylococcus, Streptococcus, and Pseudomonas. Germs can infect a surgical wound through various forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through pathogens in the air, or through organisms that are already on or in the body and then spread into the wound.

Keeping a surgical site dry or free from excessive moisture is an important objective during the post-operative course. Topical wound care is usually based on managing fluid or exudate and keeping the incision (and drain if one is present) as clean as possible.

CLASSIFICATION

Surgical site infections (SSI) are typically accompanied by one or several symptoms, including increased redness, warmth, swelling, pain, fever, chills, night sweats, nausea, vomiting, diarrhea, shortness of breath and delayed healing. SSI are classified into one of three categories, according to the Centers for Disease Control and include Superficial incisional, deep incisional and organ/space infections.1 

The extent and depth of the respective wounds impacts the associated treatment, which may include antibiotics or additional surgical intervention. How the patient and infection respond to the subsequent treatment also determines whether continued or additional intervention is required.

RISK FACTORS

Some risk factors cannot be controlled for, such as advanced age, or the need for emergency surgery. Other chronic medical conditions increase the risk for developing surgical complications, while smoking represents a modifiable condition that ideally should be addressed, especially when elective surgery is being considered.

Among other conditions that are considered risk factors for developing SSI: 

●        Having surgery that lasts more than 2 hours

●        Being overweight or morbidly obese

●        Steroids (inhibit skin repair and affect overall condition of skin as well as immune response)

●        Cancer

●        Weakened immune system

●        Diabetes

●        Having abdominal surgery

WHAT TO DO

Should you or a loved one ever find themselves in the situation where a surgical site infection may be present, it is imperative to contact your surgeon should any signs become apparent. Time is of the essence and should bacteria travel from the site of surgery into the bloodstream, sepsis (systemic infection which can result in organ failure and death) may occur.

REFERENCES

Surgical site infections. https://www.hopkinsmedicine.org/health/conditions-and-diseases/surgical-site-infections
New study documents cost and impact of chronic wounds. https://aawconline.memberclicks.net/assets/value%20in20health-economic%20impact%20of%20wounds