REVIEW ARTICLES

ACCURACY OF SURGICAL WOUND INFECTION

DEFINITIONS - THE FIRST STEP TOWARDS
SURVEILLANCE OF SURGICAL SITE INFECTIONS
Alina Petrica1, Cristina Brinzeu2, Antoniu Brinzeu2, Razvan Petrica3, Mihai Ionac4
REZUMAT
Infeciile postoperatorii reprezint o complicate frecvent ntlnit, ce se asociaz cu morbiditate i mortalitate crescut i totodat costuri ridicate pentru
sistemul sanitar. n multe centre din ntreaga lume exist o preocupare constant pentru monitorizarea infeciilor postoperatorii n vederea stabilirii dimensiunii
acestei probleme i a metodelor de prevenire a acesteia. Articolul de fa i propune s evalueze validitatea i acurateea definiiilor utilizate pentru infeciile
postoperatorii. Utilizarea unor definiii standardizate este fundamental pentru obinerea unor rezultate ct mai exacte n urma monitorizrii infeciilor de plag
postoperatorie.
Cuvinte cheie: infecie postoperatorie, controlul infeciei, plag infectat. scor ASEPSIS, scara de evaluare a plgilor Southampton

ABSTRACT
Surgical site infections (SSIs) are a common postoperative complication and represent a significant burden in terms of patient morbidity and mortality, and
cost to health services around the world.1 The surveillance of SSIs has been undertaken in many centres worldwide to ascertain the extent of the problem
and where possible, to improve the incidence rates, thereby decreasing the undesirable outcomes.2 This paper aims to assess the validity and reliability
of definitions and methods of measuring surgical wound infection. The use of standardized definitions is fundamental to the accurate measurement and
monitoring of SSIs.
Key Words: Surgical site infection (SSI), infection control, wound infection, ASEPSIS score, Southampton Wound Assessment Scale

INTRODUCTION
Surveillance is defined as the ongoing, systematic
collection, analysis, and interpretation of health data
essential to the planning, implementation, and evaluation
of public health practice, closely integrated with the
timely dissemination of these data to those who need
to know.1-3 Surveillance identifies clusters of infection,
risk factors and establishes risk indexes for infection,
provides comparisons between hospitals or surgical
specialties, and permits evaluation of control measures.4

Emergency Department, 2 Department of Anesthesiology and Intensive

Care, 3 Bega Clinic of Obstetrics and Gynecology, Clinical Emergency
County Hospital, Timisoara, 4 Division of Microsurgery, Pius Branzeu Center
for Laparoscopic Surgery and Microsurgery, Victor Babes University of
Medicine and Pharmacy, Timisoara
1

Correspondence to:
Alina Petrica, Emergency Department, County Emergency Hospital Timisoara,
10 I. Bulbuca Blvd., Timisoara, Romania, Tel. +40-747-025027.
Email: alina.petrica@urgentatm.ro
Received for publication: Sep. 11, 2009. Revised: Dec. 08, 2009.
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An ideal surveillance system should have several

attributes: meaningful definitions of infection, consistent
interpretation of classification criteria, applicability to
procedures performed in both inpatient and ambulatory
facilities, ability to detect events after discharge, sufficient
precision to distinguish small absolute differences in
attack rates, and reasonable cost.5-7
In 2001, Bruce et al made a comprehensive
review of the literature in searching for evidence for
the validity and reliability of definitions of wound
infection.8 Authors searched the MEDLINE, CINAHL,
EMBASE, Cochrane Library, and HealthSTAR databases
from 1993 to 1999 and strict inclusion and exclusion
criteria were applied to studies retrieved for appraisal.
Of 2,490 abstracts identified to assess the definition of
surgical wound infection, 90 prospective studies from
20 countries were included in the analysis. Forty-one
different definitions of surgical wound or SSI were
identified; some were standard definitions used by
national surveillance programmes: the Public Health
Laboratory Service (NPS), the Surgical Infection Society
Study Group, the Second UK National Prevalence
Survey, and the Centers for Disease Control (CDC)
1988 and 1992 definitions. There was no single symptom
common to all definitions, but the most common criteria
of infection was purulent discharge.

DEFINITIONS
The most widely recognized definition of infection,
used throughout the USA and Europe, is that devised
by Horan and colleagues and adopted by the CDC.9
According to CDC definition, surgical site infections
are classified into three groups superficial, deep
incisional SSIs and organ-space SSIs depending on
the site and the extent of infection. These definitions
are summarized in Table 1.
ASEPSIS is an acronym of seven wound assessment
parameters. (Table 2)
Its a quantitative scoring method that provides a
numerical score related to the severity of wound infection
using objective criteria based on wound appearance and
the clinical consequences of the infection.10,11

Table 1. CDC definitions of surgical site infections

The ASEPSIS system was ment to assess wounds

resulting from cardiothoracic surgery, while the
Southampton scale was designed for use in the
postoperative assessment of hernia wounds.
The Southampton system is much simpler than
the ASEPSIS system, with wounds being categorized
according to any complications and their extent.12
Both systems, however, have been developed for use
following specific types of surgery and this may limit
their usefulness.1
Southampton scale - by using the worst wound
score recorded and information about any treatment
instituted either in hospital or the community, wounds
were regarded in four categories: (Table 3)
a. normal healing;
b. minor complication;

Table 1. CDC definitions of surgical site infections.

Superficial incisional surgical site infections

Superficial incisional surgical site infections must meet the following two criteria2:
occur within 30 days of procedure
involve only the skin or subcutaneous tissue around the incision.

Plus
At least one of the following criteria:
purulent drainage from the incision
organisms isolated from an aseptically obtained culture of fluid or tissue from the incision
at least one of the following signs or symptoms of infection pain or tenderness, localized swelling, redness or heat and the incision is
deliberately opened by a surgeon, unless the culture is negative
diagnosis of superficial incisional SSI by a surgeon or attending physician.
The following are not considered superficial SSIs:
stitch abscesses (minimal inflammation and discharge confined to the points of suture penetration)
infection of an episiotomy or neonatal circumcision site
infected burn wounds
incisional SSIs that extend into the fascial and muscle layers (see deep SSIs).
Deep incisional surgical site infections
Deep incisional surgical site infections must meet the following three criteria2:
occur within 30 days of procedure (or one year in the case of implants)
are related to the procedure
involve deep soft tissues, such as the fascia and muscles.

Plus
At least one of the following criteria:
purulent drainage from the incision but not from the organ/space of the surgical site
a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of following signs or symptoms
fever (>38C), localized pain or tenderness unless the culture is negative
an abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiological examination
diagnosis of a deep incisional SSI by a surgeon or attending physician.
An organ/space SSI
An organ/space SSI must meet the following criterion:
Infection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant is in place and the infection appears to
be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or
manipulated during the operative procedure and patient has at least 1 of the following:
a. purulent drainage from a drain that is placed through a stab wound into the organ/space
b. organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
c. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic
or radiologic examination
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
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Table 3. Southampton wound scoring system

Table
2. ASEPSIS
wound
scoring system
Table
2. ASEPSIS
wound scoring
system.

Table 3. Southampton wound scoring system.

ASEPSIS WOUND SCORE

Southampton scoring system

Proportion of wound
affected

Wound characteristic
Serous exudate
Erythema
Purulent exudate
Separation of deep tissues

0 <20 20-39 40-59 60-79

>80
012345
012345
0 2 4 6 8 10
0 2 4 6 8 10

Points are scored for daily wound inspection.

Points

Criterion
Additional treatment:

Antibiotics

Drainage of pus under local anaesthesia

Debridement of wound (general

anaesthesia)

Serous discharge*

Erythema*

Purulent exudate*

Separation of deep tissues*

Isolation of bacteria

Stay as inpatient prolonged over 14 days

10
5
10
daily 0 - 5
daily 0 - 5
daily 0 - 10
daily 0 - 10
10
5

* Given score only on five of seven days. Highest weekly score used
Category of infection: total score 0 - 10 = satisfactory healing; 11 - 20 = disturbance
of healing; 20 - 30 = minor wound infection; 31 - 40 = moderate wound infection;
(Adapted from Wilson AP et al, Lancet 198611).

c. wound infection - wounds graded IV or V, or

wounds treated with antibiotics after discharge from
hospital, irrespective of the wound grading given to
them by the nurse;
d. major haematoma-wound or scrotal haematomas
requiring aspiration or evacuation.

Grade
0

Appearance
Normal healing

I Normal healing with mild bruising or erythema:

A

Some bruising

Considerable bruising

Mild erythema

II Erythema plus other signs of infl ammation

A

At one point

Around sutures

Along wound

Around wound

III Clear or haemoserous discharge:

A

At one point only (<2cm)

Along wound (>2cm)

Large volume

Prolonged (>3 days)

IV Pus:
A

At one point only (<2cm)

Along wound (>2cm)

V Deep or severe wound infection with or without tissue breakdown;

haematoma requiring aspiration

DISCUSSION

(Adapted from Bailey IS et al, BMJ 199212)

Wilson et al. in his study from 1998, compared

two standard definitions [Centers for Disease Control
(CDC), USA and National Prevalence Survey (NPS),
UK] with ASEPSIS and Southampton scales examining
325 wounds in 230 patients (divided into two groups).13
There was no significant difference between the two
surveys. The two scoring methods were more sensitive
than the standard definitions but CDC and NPS did
not differ significantly from each other. For ASEPSIS it
was reported an interrater reliability of 0.96 in patients
having general surgery and similar reliability for sternal
and leg wounds of patients after cardiac surgery.
In 2004 Wilson and Bruce made a study on 4773
patients in order to assess the level of agreement
between definitions.
The mean percentage of wounds classified as
infected differed substantially between definitions:
19.2% with the CDC definition (95% confidence
interval 18.1% to 20.4%), 14.6% (13.6% to15.6%) with
the NINSS version, 12.3% (11.4% to 13.2%) with pus
alone, and 6.8% (6.1% to 7.5%) with an ASEPSIS score
> 2014.

The agreement between definitions with respect to

individual wounds was poor. When superficial infections
(according to CDC category) were included, 13% (778)
of all observed wounds received conflicting diagnoses,
and 6% were classified as infected by both definitions.
When superficial infections were excluded, the two
definitions estimated about the same overall percentage
of infection (6.8% and 7.0% respectively), but there were
almost twice as many conflicting infection diagnoses (n
= 371) as concordant ones (n = 215). Surgical wounds
where pus was present were diagnosed as infected by the
CDC, NINSS, and pus alone definitions, but only 39%
of these (283/714) had ASEPSIS scores > 20. In these
cases, greater infection severity was often diagnosed
by CDC scale comparing with ASEPSIS. In wounds
without pus the relation of ASEPSIS and CDC scales
was less consistent. 42% (177/421) of wounds classified
only as disturbance of healing by ASEPSIS were
considered infected by the CDC definition. Conversely,
four of the six wounds classified as severe wound
infections by ASEPSIS were classified as superficial
by the CDC definition. Finally, classifications with

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different definitions disagreed for more than twice as

many wounds as those for which they agreed, and small
changes in the interpretation of a definition caused
substantial variation in the percentage of wounds
classified as infected.
Also in 2004, Chiew YF and Theis JC studied
infection rate of total hip replacement operations
using different methods of assessment of surgical
site infections. These were: (a) clinician diagnosis;
(b) ASEPSIS score; (c) presence of pus cells; and (d)
assessment by a clinical microbiologist. Two hundred and
six patients were enlisted in the study and 189 primary
replacements and 22 revision replacements were carried
out. Infection rates which were calculated according to
the risk indexes varied considerably among these four
methods. The infection rates for risk index 0 were 4.35%
(method a), 2.61% (method b), 0.87% (methods c and
d); and for risk indexes 1 and 2 were 4.17% (method a),
2.08% (method b), 1.04% (methods c and d). The CDC
NNIS approach places an important role on the surgeon
who may be more inclined to prescribe antimicrobials
for suspected infections, that being the reason for higher
rates of SSIs when the CDC definitions are used.

CONCLUSIONS
There is no validated universal system designed
specifically to aid the assessment and management of
surgical wounds. The most commonly used, the CDC
definition, employs stringent criteria to classify infection.
A single, standard definition of surgical wound infection
is needed so that comparisons over time and between
departments and institutions are valid, accurate and
useful. Meanwhile, comparisons will be compromised by

discrepancies in the way that infections are defined. So,

using wound infection rates as a performance indicator
to compare centres or countries is probably premature.

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methods of assessment for surveillance of total hip replacement
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