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Postoperative Wound Infections

Author: Mate Zabaglo Author: Stephen W. Leslie Editor: Tariq Sharman Updated: 3/5/2024 1:37:19 AM

Introduction

Surgical site infections represent the primary source of nosocomial infections in surgical patients.[1] Before the advent of the germ theory of infection and the recognition of the preventive efficacy of antisepsis, the incidence of postoperative surgical infections was alarmingly high, often resulting in limb amputation or mortality. However, the adoption of antiseptic techniques significantly ameliorated patient outcomes.[2][3][4][5][6][7]

Surgical site infections contribute significantly to postoperative morbidity and mortality rates, with current data revealing that they are responsible for over 2 million nosocomial infections in the United States.[8][9][10][11] The Centers for Disease Control and Prevention (CDC) classify surgical site infections into categories such as superficial, deep incisional, or organ/space infections. Any surgical wounds declared infected or opened by the surgeon are designated as surgical site infections. These infections must occur within 30 days following surgery or within 1 year after implantation to meet the classification criteria. For surgical site infection categories, please refer to the January 2023 CDC-National Healthcare Safety Network (NHSN) Patient Safety Component Manual for a more detailed description and information.

Superficial Incisional Infections 

These surgical site infections exclusively affect the skin and subcutaneous tissues, constituting over 50% of all surgical site infections. Diagnosis of a superficial incisional infection necessitates meeting one of the following criteria:

  • Presence of purulent discharge from the surgical site.
  • Identification of an organism from the surgical site.
  • Clinical diagnosis of a surgical site infection by the surgeon.
  • Deliberate opening of the wound by the surgeon, accompanied by at least one associated infectious symptom, such as swelling, erythema, or localized pain or warmth.

Deep Incisional Infections

These infections involve soft tissues deep into the subcutaneous tissue, including muscles and fascial planes. This diagnosis requires 1 of the following criteria:

  • Presence of purulent discharge from the surgical site.
  • Wound dehiscence.
  • Deliberate re-opening of a deep incision by the surgeon due to suspicion of infection or wound spontaneously dehisces, and a positive wound culture and at least one infectious symptom is present (eg, fever, localized pain, or tenderness)
  • Evidence of abscess formation or infection involving deep tissues, as observed on a computed tomography (CT) scan.

Organ/Space Infections

These infections may involve any organ or anatomical space beyond the incision site but deeper than the fascial or muscle layers, including implant-related infections. Diagnosis requires meeting one of the following criteria:

  • Presence of purulent discharge from a drain placed in the organ, space, or cavity.
  • Identification of an isolated organism from the involved organ, cavity, or related abscess.
  • Evidence of abscess formation or infection involving the organ, cavity, or anatomical space, as observed on a CT scan.
  • Notably, a wound is not considered infected if only a stitch abscess, localized cellulitis, or an infected superficial stab puncture is present.

Most surgical site wound infections originate from endogenous flora typically found on mucous membranes, skin, or hollow viscera. Generally, when the concentration of microbiological flora exceeds 10,000 microorganisms per gram of tissue, the risk of wound infection escalates.[12]

Etiology

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Etiology

The causes of postoperative wound infections are diverse, ranging from direct contact or airborne transmission to contamination with endogenous microbes, with susceptibility influenced by various factors. Infection patterns may vary based on the surgical procedure, operative approach, and geographical location. Risk factors can be categorized into patient and procedural factors.

Patient risk factors for wound infection include, but are not limited to, advanced age, malnutrition, hypovolemia, obesity, steroid use, poorly controlled diabetes, immunocompromised state, smoking, trauma, procedure site (intraabdominal, pelvic, or extremity), extended preoperative hospitalization, inadequate preoperative skin hygiene, and existing infections at distant sites.

Certain elective conditions can and should be optimized before surgical procedures. These factors include smoking cessation, weight loss, coagulation cascade normalization, glucose control optimization, and stabilization of other comorbidities.

Procedure-related risk factors include:

  • Abnormal fluid collection such as hematoma or seroma
  • Contamination of the surgical site, equipment, or personnel
  • Utilization of drains
  • Presence of foreign material in the surgical site
  • Hypothermia
  • Improper hair removal
  • Inadequate antibiotic prophylaxis
  • Insufficient application of the skin prep
  • Short duration of surgical preoperative scrub
  • Prolonged surgical time
  • Poor operating room (OR) ventilation
  • History of prior infection or contaminated case
  • Prolonged perioperative inpatient stay
  • Unsatisfactory surgical practices and techniques, including: 
    • Failure to maintain tissue hydration by periodic saline irrigation
    • Direct organ or tissue injury
    • Excessive tension when using traction or closing tissue
    • Excessive tissue trauma
    • Failure to remove dead or dying tissue
    • Inadequate hemostasis
    • Leaving excessive dead space
    • Overuse of cautery
    • Tissue devascularization
    • Unintended spillage of bowel contents
    • Unnecessary or prolonged use of drains [13][14][15][16]

Adherence to the preoperative and operative checklist is crucial in minimizing the rates of surgical site infections. The operating room team collectively bears the responsibility for adhering to best practices. Optimal ventilation is paramount, achieved through positive pressurization with adequate filtration, flow, and air exchange (ideally at least 15 exchanges per hour). Incoming air should be HEPA filtered and directly sourced from the outside, entering the operating room from the ceiling or a high position on the wall, while exhausts should be located near floor level.[17][18]

Reducing patient skin flora through a preoperative chlorhexidine shower is commonly advised the night before and/or on the day of surgery. Hair removal is recommended, preferably using clippers, immediately before surgery. However, clippers are not recommended before scrotal surgery due to the potential for excessive skin trauma. In most procedures and specialties, chlorhexidine and alcohol-based agents are typically preferred and recommended for skin preparation.

Tools and accessories, including stethoscopes, blood pressure cuffs, patient transfer slides, tourniquets, and computer keyboards, should be regularly cleaned to prevent bacterial contamination.[19][20][21][22][23] Surgical devices such as anesthesia or cautery units, suction machines, operating room lighting, and patient transfer aids can also serve as potential sources of contamination. Towels, sheets, and similar materials should be stored in closed cabinets or outside the operating room. Utilizing appropriate scrubbing techniques and double gloving can help reduce the incidence of postoperative infections.[24] The World Health Organization (WHO) surgical checklist aims to enhance communication, prevent complications, and improve safety and outcomes, including the prevention of surgical site infections. Surgical procedures are categorized as clean, clean-contaminated, contaminated, and dirty-infected, each associated with varying rates of postoperative wound infections.

The classification, according to the Canadian Agency for Drugs and Technologies in Health (CADTH) Report 2011, is defined as follows:

  • Clean: A procedure characterized by the absence of inflammation and maintenance of sterility. The gastrointestinal, urogenital, and pulmonary tracts are not accessed.
  • Clean-contaminated: A procedure involving entry into the gastrointestinal, urogenital, or pulmonary tracts in a controlled manner, with no existing contamination.
  • Contaminated: A procedure where a breach in sterile technique occurs and/or there is gross spillage from the gastrointestinal tract, or an incision through acutely inflamed (non-purulent) tissue. This category also includes open traumatic wounds that are 12 to 24 hours old.
  • Dirty or infected: A procedure performed on perforated viscera or an incision through acutely inflamed and purulent tissue. Open traumatic wounds older than 24 hours with necrotic tissue or fecal contamination also fall into this category.[25]

Epidemiology

Approximately 0.5% to 3% of all surgical patients will develop a surgical site infection.[26] However, the growing prevalence of outpatient surgery poses challenges in gathering comprehensive postoperative data. To address this, the NHSN has recently initiated protocols to collect data on surgical site infections resulting from procedures conducted in ambulatory surgical centers. Notably, surgical site infections often manifest after visits to ambulatory surgical centers or hospital discharge, documented in outpatient notes that may not be integrated into the hospital record. Therefore, any data reported by the CDC and NHSN should be interpreted within this contextual framework. 

Although the adoption of enhanced preventive measures has led to a decline in the incidence of surgical site infections over time, they still significantly impact morbidity and mortality. Surgical site infections contribute to 20% of all healthcare-associated infections.[27][28] Patients who develop surgical site infections face higher chances of requiring admission to an intensive care unit (ICU) and are associated with mortality risks ranging from 2 to 11 times greater. Additionally, they are 5 times more likely to experience hospital readmission. Surgical site infections constitute the most common cause of unplanned hospital readmissions in the postoperative period.[29][30][31][1][32]

In 2018, the reported incidence of surgical site infections in the United States was 157,500, with an estimated mortality of 8205. Within intensive care units (ICUs), 11% of all deaths were linked to surgical site infections. Patients with a surgical site infection typically require an additional 10 to 11 days of hospitalization on average and incur an extra financial burden exceeding $20,000 per admission. Consequently, the additional financial strain on the United States healthcare system approximates $3.3 billion annually.[27][33]

Surgical site infection rates are correlated with the degree of contamination of a surgical wound at the time of the surgical procedure (see Table).[34][35] 

Table. Surgical Site Infection Rates by Degree of Contamination

Degree of Contamination Surgical Site Infection Rates per 1000 Procedures
Clean 2.1
Clean-contaminated 3.3
Contaminated 6.4
Dirty or infected 7.1

Pathophysiology

The inciting event in developing a surgical site infection typically begins with microbial contamination of the wound. Factors such as the virulence and quantity of the contaminating organism contribute to infection, often defined as exceeding more than 105 microorganisms per gram of tissue without a foreign body. Etiologic agents of surgical site infections can be either endogenous or exogenous. Endogenous microbes originate from the patient's skin, mucous membranes, or nearby hollow viscera or may be introduced via hematogenous spread. The most common endogenous causative organisms of surgical site infections vary depending on the procedural anatomical site. For instance, following cardiac, breast, ophthalmic, orthopedic, and vascular surgeries, Staphylococcus aureus and coagulase-negative staphylococci are frequently implicated. Conversely, following abdominopelvic procedures, Enterococcus, gram-negative bacilli, and anaerobes are more commonly encountered etiologic agents.[36]

Exogenous microbes may originate from the operating theater or its inhabitants, potentially transmitted through airborne means, on instruments or materials, or via hospital staff. Among the exogenous organisms commonly identified in surgical site infections are staphylococci and streptococci. However, the prevalence of highly virulent hospital-acquired microorganisms such as methicillin-resistant S aureus (MRSA) or extended-spectrum β-lactamase microbes isolated from surgical site infections is on the rise. This trend is likely attributed to the widespread and sometimes inappropriate use of broad-spectrum antibiotics. For instance, in a study conducted in community hospitals in the southeastern US, the incidence of MRSA-associated surgical site infections increased from 12% in 2000 to 23% in 2005. Furthermore, in the 2010 NHSN update, the proportion of surgical site infections attributed to MRSA was reported to be 43.7%.[12]

History and Physical

Symptoms of surgical site infections typically manifest within 3 to 7 days following a procedure. However, by definition, these symptoms must arise within either 30 or 90 days of the procedure, depending on the specific type of surgical procedure performed. The precise timeframe varies based on the nature of the surgical intervention.[37] 

Procedures warranting a 90-day surveillance period for the development of a surgical site infection include breast surgery, cardiac surgery, coronary artery bypass graft with both chest and donor site incisions, coronary artery bypass graft with chest incision only, craniotomy, spinal fusion, open reduction of fracture, herniorrhaphy, hip prosthesis, knee prosthesis, pacemaker surgery, peripheral vascular bypass surgery, and ventricular shunt placement.

Technically challenging, prolonged, contaminated, or emergent surgical procedures of any type carry an increased risk of surgical site infection development. Patients with superficial or deep incisional surgical site infections frequently present with a gradual onset of pain around the surgical site and general malaise or fatigue. They may or may not describe incisional discharge or frequently saturated dressings. Patients with organ/space infections may describe localized or generalized pain and systemic symptoms of fevers, chills, night sweats, fatigue, or malaise. The physical examination may reveal incisional erythema, purulent or nonpurulent discharge, wound dehiscence, or delayed healing. Tenderness with palpation may be localized or more diffuse.

The physical examination of a patient with a presumptive surgical site infection should be performed in person whenever possible. However, if an in-person examination is impossible, visualization of the affected area is imperative. A study measuring the effect of introducing wound photography for situations where face-to-face meetings are impossible demonstrated improvements in diagnostic accuracy and helped prevent overtreatment.[38]

All dressings must be removed during the physical examination, and the wound should be inspected for blisters, wound tension, edema, inappropriate tenderness, excessive erythema, fluctuance, blackish-gray tissue, and evidence of ischemia or necrosis. Palpation should be performed employing a sterile technique. Whether intentional or secondary, openings in the wound should be carefully probed with a sterile cotton swab to assess for dead space, deep closure integrity, pockets of fluid, and tissue undermining. If discharge is present, purulent or otherwise, it should be sampled and sent for culture, sensitivity, and microbiological analysis.

Evaluation

The diagnosis of a surgical site infection is predominately clinical. However, wound cultures should be performed whenever possible to isolate a potential etiologic agent and guide antibiotic therapy. Imaging with ultrasound, CT, or magnetic resonance imaging (MRI) is helpful if a deep space infection is suspected. Tools are employed to predict the likelihood of developing an infection based on risk factors. Internationally recognized traditional predictive models include the National Nosocomial Infection Surveillance System, the Australian Clinical Risk Index, and the European System for Cardiac Operative Risk Evaluation. However, the clinical value of these tools is limited by the omission of many risk factors from the calculations. Additionally, some tools have weak discriminatory abilities or do not risk-stratify for specific surgeries. Specialty- and operation-specific scoring systems are emerging, including but not limited to the two-variable Infection Risk Index in Cardiac Surgery and the Surgical Site Infection Risk Score.[39][40][41][42]

Patients with superficial incisional infections typically do not demonstrate systemic signs of infection. However, fever and leukocytosis may be present. Imaging of the affected area is of limited utility and generally not recommended. Patients with deep incisional infections are likelier to demonstrate systemic signs of infection, such as fever. Laboratory evaluation typically shows leukocytosis with a left shift, and if conducted, elevated procalcitonin and C-reactive protein levels may be observed. However, inflammatory markers are not essential for diagnosis. While diagnosing a superficial incisional infection is usually straightforward, identifying a deep incisional infection solely based on clinical grounds may pose challenges, especially in patients with obesity. Imaging the affected area with ultrasound or CT can help establish the depth, extent, and anatomical involvement. Image-guided aspiration and drainage with culture can facilitate antibiotic therapy and improve outcomes.

Patients with organ/space surgical site infections typically present with systemic signs and symptoms of inflammation and infection, though superficial incisions appear uninfected. Accurately diagnosing an organ/space surgical site infection almost always requires imaging, frequently demonstrating a fluid collection or abscess in or around the surgical site. As with deep incisional infections, image-guided aspiration is of clinical utility; when available, interventional radiology should be consulted to assess suitability for drain placement.

Patients affected by necrotizing soft tissue infections represent a distinctive subset within the surgical site infection population, posing a grave threat to life with markedly elevated morbidity and mortality rates. Typically, these patients present as critically ill within the initial 48 to 72 hours following surgery and often exhibit signs of sepsis. The physical examination usually reveals pain out of proportion to the typical postoperative course, dusky or erythematous skin, peri-incisional edema, crepitus, ecchymosis, hypovascularity, blistering, or frank tissue necrosis.[43][44][45] Incisional drainage may be present in excessive amounts. Laboratory evaluation may reveal leukocytosis or leukopenia.

Necrotizing soft tissue infections may involve any tissue, including the fascia and musculature, and spread quickly along fascial or tissue planes. Imaging studies can help confirm the diagnosis but should not delay surgical wound exploration with debridement in suspected cases.[46] Fournier gangrene is a typical example of a postoperative necrotizing soft tissue infection and is a surgical emergency.[47]

Treatment / Management

Preventive Measures

Preventive measures should be taken to mitigate postoperative infections, with a checklist approach and attention to known risk factors being paramount. The "CDC and Health Infection Control Practice Advisory Committee Guideline for the Prevention of Surgical Site Infections," a comprehensive, evidence-based guideline published in 2017, is highly recommended for this purpose. These measures can be categorized into pre-procedural, perioperative, and intraoperative phases. Key pre-procedural considerations include optimizing chronic health issues such as glucose control, medication assessment, addressing chronic wounds/infections, and smoking cessation. Perioperative steps may entail preoperative showers, hair clipping, administering operation-specific antibiotics, and appropriate skin preparation. Additionally, maintaining optimal intraoperative conditions, including temperature, air circulation, and sterility, is imperative for preventing wound infections.[29][48]

A large study from Japan demonstrated a significant reduction in surgical site infections by including a perioperative oral cleaning regimen. This included removal of tartar, plaque, and scale, professional dental cleaning, optimal denture care, including adjustments, and high-quality general dental care, including extractions as needed before surgery.[49] In a large trial, the practice of changing surgical gloves and instruments immediately before abdominal wound closure resulted in a statistically significant decrease in the rate of surgical site infections. Although preliminary, these findings suggest the need for further studies to validate this approach.[50]

The routine use of surgical drains is discouraged due to uncertainty regarding their efficacy in preventing surgical site infections, and they may impede early patient mobilization.[51][52][53] If utilized, surgical drains should be promptly removed. Various measures have been taken to reduce the incidence of surgical site infections, including antibiotic irrigation, topical antimicrobial gels, antibiotic-impregnated suture material, and antiseptic dressings, among others. However, no definitive evidence currently exists demonstrating the significant efficacy of these interventions.(A1)

Delayed primary closure, commonly utilized in cases of significant contamination, has historically been employed to mitigate surgical site infections in specific patient populations. However, a meta-analysis of randomized studies did not demonstrate any significant clinical benefit associated with this practice.[54][55] Additionally, antibiotic selection tailored to the type of surgical procedure and the prevalent microbes encountered remains crucial in preventing surgical site infections.(A1)

The utilization of prophylactic negative pressure therapy in post-surgical wounds has been proposed for specific high-risk surgical cases and contaminated wounds.[56][57] Although data generally support this practice in high-risk surgeries, outcomes vary, likely due to differences in wound contamination levels and patient and wound characteristics.[58][59] Data do not suggest that the selection of surgical dressings for closed incisions significantly affects the incidence of surgical site infections.[60] However, the use of prophylactic wound protectors, available for laparoscopy, laparotomy, and orthopedic incisions, appears to be beneficial.[61][62][63][64][65][66](A1)

Treatment of Surgical Site Infections

Treatment decisions are influenced by factors such as the specific procedure performed, the types of microbes involved, anatomical considerations, and the patient's characteristics. In cases involving foreign bodies such as mesh, implants, stents, or metalwork, removal may be necessary due to contamination and the formation of biofilms.[67] Cultures are indicated for open wounds and drainage, especially if purulent, as the results will affect antibiotic selection. A negative wound culture might suggest an unusual infection with acid-fast bacteria or fungal organisms, particularly in immunocompromised patients. In such scenarios, specific cultures for these organisms should be obtained. (B2)

Systemic antibiotics are required for cases with systemic signs of infection such as fever, significant skin erythema, cellulitis, or if evidence of deeper soft tissue involvement is found. In cases where patients exhibit systemic signs of infection, obtaining blood cultures should be considered. Timely interventions in patients diagnosed with sepsis have been demonstrated to be life-saving. If the infection is superficial, treatment may be limited to local wound care.[68] The primary treatment for superficial wound infections involves opening the incision, examining the wound, draining any infected fluid collections, and debriding (removing) all necrotic tissue. This procedure is typically performed at the bedside or in the office setting. If evidence suggests deeper involvement, drainage may be conducted via interventional radiology or, if needed, in the operating room. 

Once a wound has been opened, dressings must create a clean, moisture-balanced environment while ensuring tissue is appropriately debrided and maintained at an optimal temperature to facilitate healing.[69] A balanced wound matrix prevents tissue necrosis caused by desiccation and contains growth factors that support healing, epithelial regeneration, and autolysis of dead tissue. Wound dressings tailored to specific wound environments are available. The choice of dressing type and frequency of changes depend on the wound's condition and stage of healing. Topical antiseptics such as hydrogen peroxide, dilute sodium hypochlorite, and povidone-iodine solutions may be sparingly used in infected, open wounds, but their application should be limited due to the cytotoxicity they pose to the wound matrix.

In cases where mechanical debridement cannot be performed, enzymatic agents are used.[70] Cleaning and debridement should be repeated until no necrotic or devitalized material remains and healthy granulation tissue forms. Removing any infected foreign material or implants is prioritized. 

Vacuum-assisted wound therapy utilizes negative pressure to minimize dressing changes, avoid excess fluid accumulation, and promote granulation. Vacuum-assisted wound therapy has been successfully used after major trauma, orthopedic procedures, burn surgeries, and open abdominal wounds.[71] A meta-analysis revealed a statistically significant decrease in surgical site infections following spinal surgery, along with fewer postoperative complications and shorter hospitalization durations when vacuum-assisted wound therapy was employed.[72] Similarly, another meta-analysis focusing on surgical site infections in women following cesarean sections reported similar positive outcomes with the use of vacuum-assisted closure (VAC) of wounds.[73](A1)

Wounds managed with VAC dressings may necessitate intermittent mechanical debridement. However, the use of VAC therapy requires specialized oversight, particularly when underlying organs or major blood vessels are exposed. Deep surgical site infections, especially in abdominal wounds, present unique challenges due to the risk of wound dehiscence. Consequently, exploring these wounds may be more safely conducted in the operating room. Percutaneous drainage may be considered for some cases of infected fluid collections. Notably, organ/space surgical site infections are associated with higher morbidity and mortality rates compared to other types of surgical site infections. Ultrasound and/or CT scans can facilitate the percutaneous placement of closed drains into infected fluid collections and abscesses, which may be linked to anastomotic leaks following bowel surgery. The presence of air or contrast within an intrabdominal abscess strongly suggests a bowel perforation or anastomotic leak.

Special Situations

Infections associated with the mesh, such as those occurring in hernias, typically necessitate drainage (potentially percutaneously), administration of antibiotics, wound debridement, and potential removal of the mesh. If no improvement is observed within 10 to 14 days, more aggressive intervention may be required, including surgical exploration in the operating room with likely removal of the foreign body. While a few reports indicate successful treatment with systemic and locally injected antibiotics, this approach is not considered standard of care and is generally not recommended.[74][75][76](B3)

Management of infections involving orthopedic hardware may include bone debridement, antibiotic wound therapy, long-term antibiotics, removal of orthopedic implants and associated cement, wound irrigation, and/or surgical debridement.[77] Select patients might be successfully treated with debridement and antibiotics without hardware removal, but a therapeutic failure likely requires resection arthroplasty.[78][79] Antibiotic-impregnated cement/polymer-coated intramedullary nails have demonstrated some efficacy in preliminary studies.[80] Infected vascular grafts generally require the removal of the affected section together with an alternative vascular augmentation using an uninfected area.[81][82] Compromised overlying skin may also need to be excised.[83] Partial graft excision may be reasonable in selected patients, but meta-analyses have shown a high risk of recurrent infection and the need for reoperation.[84](A1)

Using absorbable meshes that provide a structural matrix and can be designed to release factors that promote healing and tissue growth holds promise as an adjunct treatment for patients with impaired wound healing, particularly those with diabetes.[85] Additionally, hyperbaric oxygen therapy may be used for complex, non-healing postoperative wounds, with reported success rates of approximately 75% in such cases. See StatPearls' companion reference, "Hyperbaric Therapy for Wound Healing," for more information."[86](B3)

Differential Diagnosis

Generally, the presence of an incisional infection is visibly apparent. Moreover, the emergence of systemic symptoms following recent surgery should consistently prompt consideration for a postoperative issue, such as infection, leakage, or ongoing bleeding. Nevertheless, it is important to recognize that other factors can cause similar symptomatology unrelated to the wound or procedure. For instance, the patient may develop cellulitis in an area unrelated to the surgical site, exhibit an allergic reaction to antibiotics or other substances, or present with an infection only loosely connected to the surgery, such as a urinary tract infection, pneumonia, or pulmonary embolus.

Prognosis

Early recognition and prompt treatment of all surgical wounds are crucial for achieving the most favorable prognosis. However, prioritizing strict adherence to a prevention protocol represents the most prudent approach. Various models have been developed across different surgical specialties to aid in identifying high-risk patients and prevent surgical site infections. For instance, a study focusing on patients with colorectal cancer identified physiological factors, tumor characteristics, and type of surgery as reliable predictive factors for the development of surgical site infection.[87] Additionally, surgical factors such as the type of procedure, emergency surgery, wound class (dirty-infected), placement of surgical drains, surgeon experience, prolonged operating time, and certain postoperative factors like extended hospital stays and the need for intraoperative transfusions were identified as independent risk factors for surgical site infections.[88]

Complications

Complications arising from surgical wound infections can manifest locally or systemically. Local complications include delayed wound healing, which can progress to chronic wounds and result in local tissue damage. Furthermore, superimposed infections, abscess formation, and osteomyelitis may also occur as additional local complications. On the other hand, systemic complications involve bacteremia, potentially leading to distant hematogenous spread and sepsis. In severe cases of infection, organ failure may develop, or existing comorbid conditions may be exacerbated.

Postoperative and Rehabilitation Care

Postoperative wound care is key to any postoperative hospital or rehabilitation stay, as the wound may be the primary reason for the patient's in-house care. Effective wound care and healing are essential for the patient's overall well-being and, in certain situations, their survival. The field of wound care is continuously evolving into a more sophisticated specialty. Providing adequate care for postoperative wounds demands timely evaluation and deliberate interventions to achieve the most favorable outcomes for patients.

Consultations

Management of postoperative wound infections may occasionally necessitate the expertise of various specialists, including infectious disease, plastic surgery, and critical care specialists.

Deterrence and Patient Education

Certain identifiable and modifiable risk factors in patients, such as body mass index, diabetic control, and smoking status, can help minimize postoperative wound infections. Elective surgeries often entail preoperative education and counseling. Before initiating certain procedures, patients may be encouraged to lose weight, adhere to a pharmacological regimen, and maintain healthy habits. 

Smoking cessation represents another crucial step in optimizing patient risk factors. Whenever feasible, involving the patient's family in these discussions is beneficial. Recommendations and protocols differ based on preexisting conditions and the proposed or necessary surgery. For instance, a spinal surgery protocol may suggest maintaining HbA1c levels below 8%, administering α-blockers for males aged 60 and older, ensuring serum albumin levels exceed 3.5 g/dL, conducting cardiac stress tests, and emphasizing smoking cessation.[89] 

Pearls and Other Issues

Antiseptic Preoperative Prep Solutions

Iodine-based sterilizing solutions, such as povidone-iodine, function by releasing free iodine, which disrupts bacterial DNA and essential intracellular proteins. These solutions possess broad antimicrobial properties and are easily accessible, cost-effective, and safe for application on all skin surfaces. They are especially beneficial for prepping transvaginal and transurethral areas as they can be safely used on mucosal surfaces. However, caution should be exercised in patients with an iodine allergy, and these solutions should not be applied to such individuals. Typically, the skin is initially scrubbed with an iodine solution and then painted with the iodine solution for application.

Alcohol-based prep solutions are known for their broad antimicrobial activity and are valued for being inexpensive, fast, and quick-acting. A single application is typically sufficient, and they dry rapidly. Compared to iodine-based antiseptic solutions, alcohol-based ones are easier to apply, have a longer-lasting antimicrobial effect, offer greater overall efficacy, require shorter drying times, and are more cost-effective. However, alcohol-based solutions are highly flammable, necessitating caution to ensure the skin surface is completely dry before proceeding. Additionally, alcohol is not suitable for application to mucous membranes.[1]

Chlorhexidine gluconate, often applied as an aqueous solution, functions by destroying the bacterial cell membrane. Notably, it boasts a longer duration of antiseptic activity compared to iodine-based antiseptics and is more resistant to neutralization. Chlorhexidine is commonly used for preoperative patient showering, surgeon hand-scrubbing, and as a skin prep agent. A large prospective study involving nearly 7,000 patients compared chlorhexidine with iodine-based antiseptic skin prep solutions and revealed no significant difference in the surgical site infection rate.[90]

Alcohol-based solutions that contain iodine or chlorhexidine combine these benefits and generally provide longer-duration antisepsis activity than single agents. Combining agents with different modes of antimicrobial activity appears to provide additive efficacy compared to single agents.[91]

When selecting surgical prophylaxis, choosing a safe, narrow-spectrum agent that covers the expected microorganisms is important. The antibiotic should be administered 30 to 60 minutes before the initial skin incision or instrumentation to ensure therapeutic levels are reached by the start of the operation.

  • For clean procedures, antibiotics should cover skin flora, primarily staphylococci.
  • For clean-contaminated procedures, coverage should extend to include gram-negative rods and enterococci, alongside staff staphylococci, depending on the specific procedure. Common choices include cefazolin 2 g (weight-adjusted) or vancomycin 15 mg/kg in combination with metronidazole, cefoxitin, or ertapenem.
  • Antibiotic therapy should be continued for contaminated and dirty procedures based on the pre-established regimen if already initiated, or maybe adjusted intraoperatively depending on findings.*

*Note: It is often instructive to involve infectious disease and pharmacy professionals to help optimize treatment based on any culture results obtained from infected sites during the perioperative period.

Enhancing Healthcare Team Outcomes

During the perioperative period, patients interact with numerous healthcare professionals who are directly or indirectly engaged in mitigating factors associated with the risk of postoperative wound infections. Preoperatively, it is imperative to identify and address modifiable risk factors and provide the patient with appropriate counseling regarding potential risks. Although discussions about risks are primarily conducted by the nursing staff, anesthesiologists, and surgeons, the interprofessional healthcare team members must educate patients and reinforce preventive measures.

It is essential to take all reasonable measures to maintain cleanliness in the operating room, particularly around the operating table. Items such as anesthesia units, personal staff belongings like pens and cell phones, and medical equipment such as suction machines, blood pressure cuffs, Bovies, phones, intercoms, ventilation portals, and x-ray machines should be regarded as contaminated and cleaned regularly. Intraoperatively, all operating room personnel must uphold sterility and ensure an optimal surgical environment. Postoperatively, all involved clinicians influence recovery and postoperative wound infection rates.[92]

References

[1]

Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Reviews in urology. 2009 Fall:11(4):190-5     [PubMed PMID: 20111631]

[2]

O'donnell KF. Wisdom from Ignaz Semmelweis. Nursing. 2021 Oct 1:51(10):69-70. doi: 10.1097/01.NURSE.0000791776.01619.8e. Epub     [PubMed PMID: 34580267]

[3]

Cavaillon JM, Chrétien F. From septicemia to sepsis 3.0 - from Ignaz Semmelweis to Louis Pasteur. Microbes and infection. 2019 Jun-Jul:21(5-6):213-221. doi: 10.1016/j.micinf.2019.06.005. Epub 2019 Jun 27     [PubMed PMID: 31255674]

[4]

Absolon KB, Absolon MJ, Zientek R. From antisepsis to asepsis. Louis Pasteur's publication on "The germ theory and its application to medicine and surgery". Review of surgery. 1970 Jul-Aug:27(4):245-58     [PubMed PMID: 4918488]

[5]

Nakayama DK. Antisepsis and Asepsis and How They Shaped Modern Surgery. The American surgeon. 2018 Jun 1:84(6):766-771     [PubMed PMID: 29981599]

[6]

Michaleas SN, Laios K, Charalabopoulos A, Samonis G, Karamanou M. Joseph Lister (1827-1912): A Pioneer of Antiseptic Surgery. Cureus. 2022 Dec:14(12):e32777. doi: 10.7759/cureus.32777. Epub 2022 Dec 21     [PubMed PMID: 36686094]

[7]

Toledo-Pereyra LH, Toledo MM. A critical study of Lister's work on antiseptic surgery. American journal of surgery. 1976 Jun:131(6):736-44     [PubMed PMID: 779507]

[8]

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. Infection control and hospital epidemiology. 2002 Apr:23(4):183-9     [PubMed PMID: 12002232]

Level 2 (mid-level) evidence

[9]

Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerging infectious diseases. 2003 Feb:9(2):196-203     [PubMed PMID: 12603990]

Level 2 (mid-level) evidence

[10]

Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, Sloane R, Sexton DJ. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PloS one. 2009 Dec 15:4(12):e8305. doi: 10.1371/journal.pone.0008305. Epub 2009 Dec 15     [PubMed PMID: 20016850]

Level 2 (mid-level) evidence

[11]

Rahman MS, Hasan K, Ul Banna H, Raza AM, Habibullah T. A study on initial outcome of selective non-operative management in penetrating abdominal injury in a tertiary care hospital in Bangladesh. Turkish journal of surgery. 2019 Jun:35(2):117-123. doi: 10.5578/turkjsurg.4190. Epub 2019 Jun 13     [PubMed PMID: 32550316]

[12]

Young PY, Khadaroo RG. Surgical site infections. The Surgical clinics of North America. 2014 Dec:94(6):1245-64. doi: 10.1016/j.suc.2014.08.008. Epub 2014 Oct 3     [PubMed PMID: 25440122]

[13]

. Consensus paper on the surveillance of surgical wound infections. The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Infection control and hospital epidemiology. 1992 Oct:13(10):599-605     [PubMed PMID: 1334987]

Level 3 (low-level) evidence

[14]

Vitiello R, Perna A, Peruzzi M, Pitocco D, Marco G. Clinical evaluation of tibiocalcaneal arthrodesis with retrograde intramedullary nail fixation in diabetic patients. Acta orthopaedica et traumatologica turcica. 2020 May:54(3):255-261. doi: 10.5152/j.aott.2020.03.334. Epub     [PubMed PMID: 32544061]

[15]

Albertini R, Coluccia A, Colucci ME, Zoni R, Affanni P, Veronesi L, Pasquarella C. An overview of the studies on microbial air contamination in operating theatres and related issues over time: a useful tool for a multidisciplinary approach. Acta bio-medica : Atenei Parmensis. 2023 Aug 30:94(S3):e2023149. doi: 10.23750/abm.v94iS3.14507. Epub 2023 Aug 30     [PubMed PMID: 37695181]

Level 3 (low-level) evidence

[16]

Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC, Saiman L, Yokoe DS, Maragakis LL, Kaye KS. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection control and hospital epidemiology. 2014 Jun:35(6):605-27. doi: 10.1086/676022. Epub     [PubMed PMID: 24799638]

[17]

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infection control and hospital epidemiology. 1999 Apr:20(4):250-78; quiz 279-80     [PubMed PMID: 10219875]

Level 1 (high-level) evidence

[18]

Macefield RC, Reeves BC, Milne TK, Nicholson A, Blencowe NS, Calvert M, Avery KN, Messenger DE, Bamford R, Pinkney TD, Blazeby JM. Development of a single, practical measure of surgical site infection (SSI) for patient report or observer completion. Journal of infection prevention. 2017 Jul:18(4):170-179. doi: 10.1177/1757177416689724. Epub 2017 Feb 1     [PubMed PMID: 28989524]

[19]

Fellowes C, Kerstein R, Clark J, Azadian BS. MRSA on tourniquets and keyboards. The Journal of hospital infection. 2006 Sep:64(1):86-8     [PubMed PMID: 16824648]

Level 3 (low-level) evidence

[20]

Messina G, Ceriale E, Lenzi D, Burgassi S, Azzolini E, Manzi P. Environmental contaminants in hospital settings and progress in disinfecting techniques. BioMed research international. 2013:2013():429780. doi: 10.1155/2013/429780. Epub 2013 Oct 30     [PubMed PMID: 24286078]

[21]

De Groote P, Blot K, Conoscenti E, Labeau S, Blot S. Mobile phones as a vector for Healthcare-Associated Infection: A systematic review. Intensive & critical care nursing. 2022 Oct:72():103266. doi: 10.1016/j.iccn.2022.103266. Epub 2022 Jun 7     [PubMed PMID: 35688751]

Level 1 (high-level) evidence

[22]

Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial contamination of keyboards: efficacy and functional impact of disinfectants. Infection control and hospital epidemiology. 2006 Apr:27(4):372-7     [PubMed PMID: 16622815]

[23]

Brady RR, Fraser SF, Dunlop MG, Paterson-Brown S, Gibb AP. Bacterial contamination of mobile communication devices in the operative environment. The Journal of hospital infection. 2007 Aug:66(4):397-8     [PubMed PMID: 17573157]

Level 3 (low-level) evidence

[24]

Spagnolo AM, Ottria G, Amicizia D, Perdelli F, Cristina ML. Operating theatre quality and prevention of surgical site infections. Journal of preventive medicine and hygiene. 2013 Sep:54(3):131-7     [PubMed PMID: 24783890]

Level 2 (mid-level) evidence

[25]

Kamel C, McGahan L, Mierzwinski-Urban M, Embil J. Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines. 2011 Jun:():     [PubMed PMID: 24354038]

[26]

Seidelman JL, Mantyh CR, Anderson DJ. Surgical Site Infection Prevention: A Review. JAMA. 2023 Jan 17:329(3):244-252. doi: 10.1001/jama.2022.24075. Epub     [PubMed PMID: 36648463]

[27]

Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY, Duane TM. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons. 2017 Jan:224(1):59-74. doi: 10.1016/j.jamcollsurg.2016.10.029. Epub 2016 Nov 30     [PubMed PMID: 27915053]

[28]

Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surgical infections. 2012 Aug:13(4):234-7. doi: 10.1089/sur.2012.131. Epub 2012 Aug 22     [PubMed PMID: 22913334]

[29]

Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP, Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA surgery. 2017 Aug 1:152(8):784-791. doi: 10.1001/jamasurg.2017.0904. Epub     [PubMed PMID: 28467526]

[30]

Lewis SS, Moehring RW, Chen LF, Sexton DJ, Anderson DJ. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infection control and hospital epidemiology. 2013 Nov:34(11):1229-30. doi: 10.1086/673443. Epub     [PubMed PMID: 24113613]

[31]

Merkow RP, Ju MH, Chung JW, Hall BL, Cohen ME, Williams MV, Tsai TC, Ko CY, Bilimoria KY. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015 Feb 3:313(5):483-95. doi: 10.1001/jama.2014.18614. Epub     [PubMed PMID: 25647204]

[32]

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. Infection control and hospital epidemiology. 1999 Nov:20(11):725-30     [PubMed PMID: 10580621]

Level 2 (mid-level) evidence

[33]

Zimlichman E,Henderson D,Tamir O,Franz C,Song P,Yamin CK,Keohane C,Denham CR,Bates DW, Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA internal medicine. 2013 Dec 9-23;     [PubMed PMID: 23999949]

Level 1 (high-level) evidence

[34]

Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. The American journal of medicine. 1991 Sep 16:91(3B):152S-157S     [PubMed PMID: 1656747]

[35]

López Pereira P, Díaz-Agero Pérez C, López Fresneña N, Las Heras Mosteiro J, Palancar Cabrera A, Rincón Carlavilla ÁL, Aranaz Andrés JM. 'Epidemiology of surgical site infection in a neurosurgery department'. British journal of neurosurgery. 2017 Feb:31(1):10-15. doi: 10.1080/02688697.2016.1260687. Epub 2016 Dec 1     [PubMed PMID: 27905216]

[36]

Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. The Journal of hospital infection. 2008 Nov:70 Suppl 2():3-10. doi: 10.1016/S0195-6701(08)60017-1. Epub     [PubMed PMID: 19022115]

[37]

Russo V, Leaptrot D, Otis M, Smith H, Hebden JN, Wright MO. Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network Data Quality Collaboration Case Study - Chapter 9 Surgical site infection event (SSI) case study. American journal of infection control. 2022 Jul:50(7):799-800. doi: 10.1016/j.ajic.2022.03.036. Epub 2022 Apr 10     [PubMed PMID: 35417770]

Level 2 (mid-level) evidence

[38]

Sanger PC, Simianu VV, Gaskill CE, Armstrong CA, Hartzler AL, Lordon RJ, Lober WB, Evans HL. Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study. Journal of the American College of Surgeons. 2017 Jan:224(1):8-15.e1. doi: 10.1016/j.jamcollsurg.2016.10.027. Epub 2016 Oct 14     [PubMed PMID: 27746223]

[39]

van Walraven C, Musselman R. The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PloS one. 2013:8(6):e67167. doi: 10.1371/journal.pone.0067167. Epub 2013 Jun 27     [PubMed PMID: 23826224]

[40]

Bustamante-Munguira J, Herrera-Gómez F, Ruiz-Álvarez M, Figuerola-Tejerina A, Hernández-Aceituno A. A New Surgical Site Infection Risk Score: Infection Risk Index in Cardiac Surgery. Journal of clinical medicine. 2019 Apr 9:8(4):. doi: 10.3390/jcm8040480. Epub 2019 Apr 9     [PubMed PMID: 30970636]

[41]

Emori TG, Culver DH, Horan TC, Jarvis WR, White JW, Olson DR, Banerjee S, Edwards JR, Martone WJ, Gaynes RP. National nosocomial infections surveillance system (NNIS): description of surveillance methods. American journal of infection control. 1991 Feb:19(1):19-35     [PubMed PMID: 1850582]

[42]

Figuerola-Tejerina A, Bustamante E, Tamayo E, Mestres CA, Bustamante-Munguira J. Ability to predict the development of surgical site infection in cardiac surgery using the Australian Clinical Risk Index versus the National Nosocomial Infections Surveillance-derived Risk Index. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology. 2017 Jun:36(6):1041-1046. doi: 10.1007/s10096-016-2889-0. Epub 2017 Jan 19     [PubMed PMID: 28105547]

[43]

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. The New England journal of medicine. 2017 Dec 7:377(23):2253-2265. doi: 10.1056/NEJMra1600673. Epub     [PubMed PMID: 29211672]

[44]

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Jul 15:59(2):147-59. doi: 10.1093/cid/ciu296. Epub 2014 Jun 18     [PubMed PMID: 24947530]

Level 1 (high-level) evidence

[45]

Hua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N, Chosidow O. Necrotising soft-tissue infections. The Lancet. Infectious diseases. 2023 Mar:23(3):e81-e94. doi: 10.1016/S1473-3099(22)00583-7. Epub 2022 Oct 14     [PubMed PMID: 36252579]

[46]

Leslie SW, Rad J, Foreman J. Fournier Gangrene. StatPearls. 2024 Jan:():     [PubMed PMID: 31747228]

[47]

Nagle SM, Stevens KA, Wilbraham SC. Wound Assessment. StatPearls. 2024 Jan:():     [PubMed PMID: 29489199]

[48]

Walker J. Reducing the risk of surgical site infections. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2023 Oct 4:38(10):77-81. doi: 10.7748/ns.2023.e12185. Epub 2023 Sep 11     [PubMed PMID: 37691566]

[49]

Shimane T, Koike K, Fujita S, Kurita H, Isomura ET, Chikazu D, Kanno N, Sasaki K, Hino S, Hibi H, Koyama T, Nakamura S, Nomura T, Mori Y, Tojyo I, Yamamoto T, Yamamori I, Aota K, Tanzawa H. Positive impact of perioperative oral management on the risk of surgical site infections after abdominal surgery: Sixteen universities in Japan. Medicine. 2023 Sep 15:102(37):e35066. doi: 10.1097/MD.0000000000035066. Epub     [PubMed PMID: 37713859]

[50]

Ferreira J, Joos E, Bhandari M, Dixon E, Brown CJ, Evidence-Based Reviews in Surgery Group. Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection: Reviewing the ChEETAh Trial. Journal of the American College of Surgeons. 2024 Jan 1:238(1):139-143. doi: 10.1097/XCS.0000000000000866. Epub 2023 Sep 18     [PubMed PMID: 37721383]

[51]

Muthu S, Ramakrishnan E, Natarajan KK, Chellamuthu G. Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2020 Sep:29(9):2111-2128. doi: 10.1007/s00586-020-06540-2. Epub 2020 Jul 22     [PubMed PMID: 32700123]

Level 1 (high-level) evidence

[52]

Yang J, Liu Y, Yan P, Tian H, Jing W, Si M, Yang K, Guo T. Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis. Medicine. 2020 May:99(20):e20070. doi: 10.1097/MD.0000000000020070. Epub     [PubMed PMID: 32443316]

Level 1 (high-level) evidence

[53]

Holubar SD,Hedrick T,Gupta R,Kellum J,Hamilton M,Gan TJ,Mythen MG,Shaw AD,Miller TE, American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioperative medicine (London, England). 2017     [PubMed PMID: 28270910]

Level 2 (mid-level) evidence

[54]

Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA surgery. 2013 Aug:148(8):779-86. doi: 10.1001/jamasurg.2013.2336. Epub     [PubMed PMID: 23803860]

Level 1 (high-level) evidence

[55]

He JC, Zosa BM, Schechtman D, Brajcich B, Savakus JC, Wojahn AL, Wang DZ, Claridge JA. Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught. Surgical infections. 2017 May/Jun:18(4):431-439. doi: 10.1089/sur.2017.018. Epub 2017 Mar 23     [PubMed PMID: 28332921]

[56]

Wang C, Zhang Y, Qu H. Negative pressure wound therapy for closed incisions in orthopedic trauma surgery: a meta-analysis. Journal of orthopaedic surgery and research. 2019 Dec 11:14(1):427. doi: 10.1186/s13018-019-1488-z. Epub 2019 Dec 11     [PubMed PMID: 31829217]

Level 1 (high-level) evidence

[57]

Gombert A, Dillavou E, D'Agostino R Jr, Griffin L, Robertson JM, Eells M. A systematic review and meta-analysis of randomized controlled trials for the reduction of surgical site infection in closed incision management versus standard of care dressings over closed vascular groin incisions. Vascular. 2020 Jun:28(3):274-284. doi: 10.1177/1708538119890960. Epub 2020 Jan 19     [PubMed PMID: 31955666]

Level 1 (high-level) evidence

[58]

Kuper TM, Murphy PB, Kaur B, Ott MC. Prophylactic Negative Pressure Wound Therapy for Closed Laparotomy Incisions: A Meta-analysis of Randomized Controlled Trials. Annals of surgery. 2020 Jan:271(1):67-74. doi: 10.1097/SLA.0000000000003435. Epub     [PubMed PMID: 31860549]

Level 1 (high-level) evidence

[59]

Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi WJ, Karanicolas PJ. The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: A systematic review and meta-analysis. Surgery. 2020 Jun:167(6):1001-1009. doi: 10.1016/j.surg.2020.01.018. Epub 2020 Mar 3     [PubMed PMID: 32143842]

Level 1 (high-level) evidence

[60]

Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, Blencowe N, Milne TK, Reeves BC, Blazeby J. Dressings for the prevention of surgical site infection. The Cochrane database of systematic reviews. 2016 Dec 20:12(12):CD003091. doi: 10.1002/14651858.CD003091.pub4. Epub 2016 Dec 20     [PubMed PMID: 27996083]

Level 1 (high-level) evidence

[61]

Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG. Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Annals of surgery. 2012 Jul:256(1):53-9. doi: 10.1097/SLA.0b013e3182570372. Epub     [PubMed PMID: 22584694]

Level 1 (high-level) evidence

[62]

Liu JB, Baker MS, Thompson VM, Kilbane EM, Pitt HA. Wound protectors mitigate superficial surgical site infections after pancreatoduodenectomy. HPB : the official journal of the International Hepato Pancreato Biliary Association. 2019 Jan:21(1):121-131. doi: 10.1016/j.hpb.2018.07.006. Epub 2018 Aug 1     [PubMed PMID: 30077524]

[63]

Kobayashi H, Uetake H, Yasuno M, Sugihara K. Effectiveness of Wound-Edge Protectors for Preventing Surgical Site Infections after Open Surgery for Colorectal Disease: A Prospective Cohort Study with Two Parallel Study Groups. Digestive surgery. 2019:36(1):83-88. doi: 10.1159/000488214. Epub 2018 Apr 26     [PubMed PMID: 29698971]

[64]

Bressan AK, Roberts DJ, Edwards JP, Bhatti SU, Dixon E, Sutherland FR, Bathe O, Ball CG. Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple's procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial. BMJ open. 2014 Aug 21:4(8):e005577. doi: 10.1136/bmjopen-2014-005577. Epub 2014 Aug 21     [PubMed PMID: 25146716]

Level 1 (high-level) evidence

[65]

Luo Y, Qiu YE, Mu YF, Qin SL, Qi Y, Zhong M, Yu MH, Ma LY. Plastic wound protectors decreased surgical site infections following laparoscopic-assisted colectomy for colorectal cancer: A retrospective cohort study. Medicine. 2017 Sep:96(37):e7752. doi: 10.1097/MD.0000000000007752. Epub     [PubMed PMID: 28906360]

Level 2 (mid-level) evidence

[66]

Mihaljevic AL, Schirren R, Özer M, Ottl S, Grün S, Michalski CW, Erkan M, Jäger C, Reiser-Erkan C, Kehl V, Schuster T, Roder J, Clauer U, Orlitsch C, Hoffmann TF, Lange R, Harzenetter T, Steiner P, Michalski M, Henkel K, Stadler J, Pistorius GA, Jahn A, Obermaier R, Unger R, Strunk R, Willeke F, Vogelsang H, Halve B, Dietl KH, Hilgenstock H, Meyer A, Krämling HJ, Wagner M, Schoenberg MH, Zeller F, Schmidt J, Friess H, Kleeff J. Multicenter double-blinded randomized controlled trial of standard abdominal wound edge protection with surgical dressings versus coverage with a sterile circular polyethylene drape for prevention of surgical site infections: a CHIR-Net trial (BaFO; NCT01181206). Annals of surgery. 2014 Nov:260(5):730-7; discussion 737-9. doi: 10.1097/SLA.0000000000000954. Epub     [PubMed PMID: 25379844]

Level 1 (high-level) evidence

[67]

Lall RR, Wong AP, Lall RR, Lawton CD, Smith ZA, Dahdaleh NS. Evidence-based management of deep wound infection after spinal instrumentation. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2015 Feb:22(2):238-42. doi: 10.1016/j.jocn.2014.07.010. Epub 2014 Oct 11     [PubMed PMID: 25308619]

Level 2 (mid-level) evidence

[68]

Yin D, Liu B, Chang Y, Gu H, Zheng X. Management of late-onset deep surgical site infection after instrumented spinal surgery. BMC surgery. 2018 Dec 22:18(1):121. doi: 10.1186/s12893-018-0458-4. Epub 2018 Dec 22     [PubMed PMID: 30577832]

[69]

Ovington LG. Hanging wet-to-dry dressings out to dry. Home healthcare nurse. 2001 Aug:19(8):477-83; quiz 484     [PubMed PMID: 11982183]

[70]

Steed DL. Debridement. American journal of surgery. 2004 May:187(5A):71S-74S     [PubMed PMID: 15147995]

[71]

Ding J, Zhu Y, Ge H, Chen H, Wang L, Xie S, Zhang S, Deng Y, Yang R, Guo H. Negative Pressure Wound Therapy for Patients With Complicated Mucocutaneous Separation Following Ileal Conduit Urinary Diversion: A Case Series. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2023 Sep-Oct 01:50(5):420-426. doi: 10.1097/WON.0000000000001000. Epub     [PubMed PMID: 37713355]

Level 2 (mid-level) evidence

[72]

Lu S, Yuan Z, He X, Du Z, Wang Y. The impact of negative pressure wound therapy on surgical wound infection, hospital stay and postoperative complications after spinal surgery: A meta-analysis. International wound journal. 2024 Jan:21(1):e14378. doi: 10.1111/iwj.14378. Epub 2023 Sep 11     [PubMed PMID: 37697710]

Level 1 (high-level) evidence

[73]

Zhu Y, Dai L, Luo B, Zhang L. Meta-analysis of prophylactic negative pressure wound therapy for surgical site infections (SSI) in caesarean section surgery. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2023 Jun:18(2):224-234. doi: 10.5114/wiitm.2023.125913. Epub 2023 Mar 20     [PubMed PMID: 37680737]

Level 1 (high-level) evidence

[74]

Alston D, Parnell S, Hoonjan B, Sebastian A, Howard A. Conservative management of an infected laparoscopic hernia mesh: A case study. International journal of surgery case reports. 2013:4(11):1035-7. doi: 10.1016/j.ijscr.2013.08.008. Epub 2013 Aug 27     [PubMed PMID: 24099982]

Level 3 (low-level) evidence

[75]

Aguilar B, Chapital AB, Madura JA 2nd, Harold KL. Conservative management of mesh-site infection in hernia repair. Journal of laparoendoscopic & advanced surgical techniques. Part A. 2010 Apr:20(3):249-52. doi: 10.1089/lap.2009.0274. Epub     [PubMed PMID: 20156120]

Level 3 (low-level) evidence

[76]

Trunzo JA, Ponsky JL, Jin J, Williams CP, Rosen MJ. A novel approach for salvaging infected prosthetic mesh after ventral hernia repair. Hernia : the journal of hernias and abdominal wall surgery. 2009 Oct:13(5):545-9. doi: 10.1007/s10029-009-0470-9. Epub 2009 Feb 12     [PubMed PMID: 19214650]

Level 3 (low-level) evidence

[77]

Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. The Journal of bone and joint surgery. British volume. 2005 Feb:87(2):249-56     [PubMed PMID: 15736752]

[78]

Geurts JA, Janssen DM, Kessels AG, Walenkamp GH. Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta orthopaedica. 2013 Dec:84(6):509-16. doi: 10.3109/17453674.2013.858288. Epub 2013 Oct 31     [PubMed PMID: 24171687]

Level 2 (mid-level) evidence

[79]

Van Kleunen JP, Knox D, Garino JP, Lee GC. Irrigation and débridement and prosthesis retention for treating acute periprosthetic infections. Clinical orthopaedics and related research. 2010 Aug:468(8):2024-8. doi: 10.1007/s11999-010-1291-y. Epub     [PubMed PMID: 20224960]

[80]

Solanki T, Maurya MK, Singh PK. Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones. Cureus. 2023 Aug:15(8):e43421. doi: 10.7759/cureus.43421. Epub 2023 Aug 13     [PubMed PMID: 37706117]

[81]

Bosman PJ, Blankestijn PJ, van der Graaf Y, Heintjes RJ, Koomans HA, Eikelboom BC. A comparison between PTFE and denatured homologous vein grafts for haemodialysis access: a prospective randomised multicentre trial. The SMASH Study Group. Study of Graft Materials in Access for Haemodialysis. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 1998 Aug:16(2):126-32     [PubMed PMID: 9728431]

Level 1 (high-level) evidence

[82]

Benrashid E, Youngwirth LM, Mureebe L, Lawson JH. Operative and perioperative management of infected arteriovenous grafts. The journal of vascular access. 2017 Jan 18:18(1):13-21. doi: 10.5301/jva.5000613. Epub 2016 Nov 3     [PubMed PMID: 27834454]

[83]

McKenna PJ, Leadbetter MG. Salvage of chronically exposed Gore-Tex vascular access grafts in the hemodialysis patient. Plastic and reconstructive surgery. 1988 Dec:82(6):1046-51     [PubMed PMID: 3200941]

[84]

Tullavardhana T, Chartkitchareon A. Meta-analysis of total versus partial graft excision: Which is the better choice to manage arteriovenous dialysis graft infection? Annals of Saudi medicine. 2022 Sep-Oct:42(5):343-350. doi: 10.5144/0256-4947.2022.343. Epub 2022 Oct 6     [PubMed PMID: 36252149]

Level 1 (high-level) evidence

[85]

Vasalou V, Kotidis E, Tatsis D, Boulogeorgou K, Grivas I, Koliakos G, Cheva A, Ioannidis O, Tsingotjidou A, Angelopoulos S. The Effects of Tissue Healing Factors in Wound Repair Involving Absorbable Meshes: A Narrative Review. Journal of clinical medicine. 2023 Aug 31:12(17):. doi: 10.3390/jcm12175683. Epub 2023 Aug 31     [PubMed PMID: 37685753]

Level 3 (low-level) evidence

[86]

Jones MW, Cooper JS. Hyperbaric Therapy for Wound Healing. StatPearls. 2024 Jan:():     [PubMed PMID: 29083562]

[87]

Sagawa M, Yokomizo H, Yoshimatsu K, Yano Y, Okayama S, Sakuma A, Satake M, Yamada Y, Usui T, Yamaguchi K, Shiozawa S, Shimakawa T, Katsube T, Kato H, Naritaka Y. [Relationship between Surgical Site Infection(SSI)Incidence and Prognosis in Colorectal Cancer Surgery]. Gan to kagaku ryoho. Cancer & chemotherapy. 2017 Oct:44(10):921-923     [PubMed PMID: 29066696]

[88]

Isik O, Kaya E, Dundar HZ, Sarkut P. Surgical Site Infection: Re-assessment of the Risk Factors. Chirurgia (Bucharest, Romania : 1990). 2015 Sep-Oct:110(5):457-61     [PubMed PMID: 26531790]

[89]

Epstein NE. Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery. Surgical neurology international. 2018:9():251. doi: 10.4103/sni.sni_372_18. Epub 2018 Dec 11     [PubMed PMID: 30637169]

[90]

Ghobrial GM, Wang MY, Green BA, Levene HB, Manzano G, Vanni S, Starke RM, Jimsheleishvili G, Crandall KM, Dididze M, Levi AD. Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients. Journal of neurosurgery. Spine. 2018 Feb:28(2):209-214. doi: 10.3171/2017.5.SPINE17158. Epub 2017 Nov 24     [PubMed PMID: 29171793]

[91]

Hibbard JS. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. Journal of infusion nursing : the official publication of the Infusion Nurses Society. 2005 May-Jun:28(3):194-207     [PubMed PMID: 15912075]

[92]

Anderson PA, Savage JW, Vaccaro AR, Radcliff K, Arnold PM, Lawrence BD, Shamji MF. Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery. 2017 Mar 1:80(3S):S114-S123. doi: 10.1093/neuros/nyw066. Epub     [PubMed PMID: 28350942]