See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/221803176

Contributing Factors to Surgical Site Infections

Article  in  The Journal of the American Academy of Orthopaedic Surgeons · February 2012

DOI: 10.5435/JAAOS-20-02-094 · Source: PubMed

CITATIONS READS
93 741

6 authors, including:

James S Harrop John C. Styliaras

Thomas Jefferson University Thomas Jefferson University Hospitals
421 PUBLICATIONS   9,967 CITATIONS    4 PUBLICATIONS   102 CITATIONS   

SEE PROFILE SEE PROFILE

Yinn Cher Ooi Chengyuan Wu

University of California, Los Angeles Thomas Jefferson University
25 PUBLICATIONS   332 CITATIONS    74 PUBLICATIONS   598 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Clinical Guidelines View project

CNS and Abdominal Radiology View project

All content following this page was uploaded by James S Harrop on 24 July 2016.

The user has requested enhancement of the downloaded file.

 Review Article

Contributing Factors to Surgical

Site Infections

James S. Harrop, MD
John C. Styliaras, MD
Yinn Cher Ooi
Kristen E. Radcliff, MD
Alexander R. Vaccaro, MD
Chengyuan Wu, MD
Abstract
Surgical site infections (SSIs) are the most common nosocomial
infections. These complications lead to revision surgery, delayed
wound healing, increased use of antibiotics, and increased length
of hospital stay, all of which have a significant impact on patients
and the cost of health care. Such intraoperative factors as proper
skin preparation, adherence to sterile technique, surgical duration,
and traffic in the operating room contribute more to SSIs than do
patient-related risk factors such as diabetes mellitus, obesity, and
preexisting colonization with methicillin-resistant Staphylococcus
aureus. Surgeons have a responsibility to understand the current
evidence regarding the factors that affect the rates of SSIs so as to
provide the highest level of patient care.

S urgical site infections (SSIs) are the

From the Department of
Neurosurgery (Dr. Harrop,
Dr. Styliaras, Mr. Ooi, and Dr. Wu)
and the Department of Orthopaedic
Surgery (Dr. Radcliff and
Dr. Vaccaro), Thomas Jefferson
University, Philadelphia, PA.
J Am Acad Orthop Surg 2012;20:94-
101
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
most common form of nosocomial
infection; 300,000 to 500,000 cases oc-
cur annually in the United States.1
Various risk factors are associated
with SSI, including patient age, dia-
betes, obesity, urinary incontinence,
tobacco use, poor nutritional status,
complete neurologic deficit, revision
surgery, use of nonsteroidal anti-
inflammatory drugs, blood transfu-
sion, prolonged surgical time, and
the presence of more than three co-
morbid diseases.1,2 Sequelae of SSIs
include revision surgery, delayed
wound healing, increased use of anti-
biotics, and increased length of hos-
pital stay.2 These result in more than
$1.5 billion in additional annual
costs in the United States.2 SSIs are
also responsible for approximately
77% of all deaths in patients with
nosocomial infection.1,2
Antiseptic Agents
The primary agents used for antisep-
sis include alcohol, iodine, and chlor-
hexidine. These agents, either alone
or in combination, are used in hand
washing and for preoperative skin
preparations.
Alcohol is the oldest antiseptic
agent and remains one of the most
effective, providing the most rapid
and greatest reduction in bacterial
counts. Its duration of action is fair
in comparison with povidone-iodine
and chlorhexidine.2,3
Povidone is a carrier polymer that
prolongs the activity of iodine by re-
leasing it slowly. The mechanism of
action of povidone-iodine involves
iodination of lipids and oxidation of
both cytoplasmic and membrane
compounds. Povidone-iodine has
bactericidal effects against bacteria,
fungi, protozoa, and viruses.2,3 An-
other formulation, iodine povacrylex
combined with alcohol, is used pri-
marily for preoperative skin prepara-
tion.
Chlorhexidine works by a similar
mechanism of membrane disruption;
it has bactericidal and bacteriostatic
effects, depending on the concentra-

94 Journal of the American Academy of Orthopaedic Surgeons

 James S. Harrop, MD, et al

tion used. Compared with povidone-
iodine, chlorhexidine is felt to be
more effective against gram-positive
organisms and therefore more effec-
tive at diminishing skin colonization
by Staphylococcus species. More-
over, the effects of chlorhexidine are
immediate and more persistent than
the effects of povidone-iodine. Chlor-
hexidine has residual antimicrobial
properties because of its ability to
better bind to the skin.2,3
Hand Washing
Hand washing is still felt to be the
single most critical measure in reduc-
ing the risk of transmitting microor-
ganisms.4 It removes transient micro-
organisms and helps reduce the
number of resident microorganisms.
In terms of hand washing before sur-
gical procedures, however, consider-
able controversy exists regarding the
efficacy of measures taken to reduce
SSIs. Although gloves provide a
physical barrier, a breach in the in-
tegrity of surgical gloves can occur,
which is why hand washing is impor-
tant in reducing the incidence of in-
fection.5 Several studies specifically
address the efficacy of different scrub
protocols.1,5-7
Traditional Scrub Versus
Dry Scrub
Dispute exists regarding the efficacy
of traditional hand scrubbing com-
pared with newer dry aqueous rub
preparations (ie, dry scrub). In 2002,
a randomized controlled trial was
performed involving multiple centers
in France.7 A 5-minute traditional
scrub was compared with a 5-mL
aqueous alcohol rub preceded with
nonsterile hand washing to mechani-
cally remove debris. No statistically
significant difference in SSI rates was
found. The infection rate was 2.48%
with traditional scrubbing and
2.44% with the aqueous solution.
This study also demonstrated im-
proved compliance with use of the
dry scrub.7 One reason for this dif-
ference is that the protocol for the
dry scrub is based on the amount of
solution used; thus, the length of
time required for it to dry completely
was more consistent from one medi-
cal professional to another. Another
reason noted was that the dry scrub
caused less skin irritation and dry-
ness. Moreover, skin irritation asso-
ciated with traditional scrubbing is
felt to damage the skin and lead to
increased bacterial shedding by ex-
posing more resident microorgan-
isms. These results appear to be con-
sistent with those of other studies
comparing traditional and dry scrub
protocols.5
Selecting an Antiseptic
Agent
Selection of antiseptic agent is an-
other important aspect of preopera-
tive hand washing. Parienti et al7
compared three primary agents (ie,
alcohol, chlorhexidine, iodine) by
measuring bacterial counts at distinct
intervals after hand washing. Alco-
hol was associated with the most
rapid and greatest reduction in
colony-forming units (CFUs). In test-
ing different types and concentra-
tions of alcohol, it was found that al-
though the concentration was related
to the reduction in CFUs, the type of
alcohol used was not significant.
Chlorhexidine also demonstrated a
reasonable reduction in CFUs; more
importantly, however, this agent had
more persistent activity, which can
be attributed to increased binding to
the skin. Iodine was associated with
the smallest reduction in CFUs and
had little to no residual effect. Bacte-
ria returned to baseline levels after 6
hours.
The increased efficacy of chlorhex-
idine compared with povidone-
iodine has been demonstrated in at
least four other trials.5 Although al-
cohol has been shown to be the most
effective agent in reducing CFUs,
chlorhexidine demonstrates persis-
tent and longer-acting effects. There-
fore, alcohol plus chlorhexidine is
thought to be the most effective anti-
septic agent.5
Scrub Duration
The effect of the duration of preoper-
ative hand scrubbing also has been

Dr. Harrop or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy,
Stryker, and Neurostem; serves as a paid consultant to DePuy; serves as an unpaid consultant to Geron; and owns stock or stock
options held in AxioMed. Dr. Vaccaro or an immediate family member has received royalties from Aesculap/B. Braun Melsungen AG,
DePuy, Globus Medical, Medtronic Sofamor Danek, K2M, Stout Medical Group, Progressive Spinal Technologies, and Advanced
Spinal Intellectual Properties; serves as a paid consultant to Benvenue Medical; owns stock or stock options held in Globus Medical,
Disc Motion Technologies, Progressive Spinal Technologies, Advanced Spinal Intellectual Properties, Computational Biodynamics,
Stout Medical Group, Paradigm Spine, K2M, Replication Medical, Spineology, SpineMedica, Orthovita, VertiFlex, Small Bone
Innovations, NeuCore, CrossCurrent, Syndicom, InVivo Therapeutics, Flagship Surgical, PearlDiver Technologies, Location Based
Intelligence, and Gamma Spine; has received research or institutional support from AO North America and Cerapedics; has received
nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as
paid travel) from Stryker (Spine Education Grant); and serves as a board member, owner, officer, or committee member of the North
American Spine Society, American Spine Injury Association, Cervical Spine Research Society, and AO North America. Dr. Wu or an
immediate family member is an employee of Johnson & Johnson. None of the following authors or any immediate family member has
received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of
this article: Dr. Styliaras, Mr. Ooi, and Dr. Radcliff.

February 2012, Vol 20, No 2 95

Contributing Factors to Surgical Site Infections
studied. The current recommenda-
tion by the Centers for Disease Con-
trol and Prevention is to scrub for 2
to 6 minutes. In 2008, a Cochrane
review showed no significant differ-
ence in bacterial counts between a
2-minute traditional scrub and a
3-minute traditional scrub.5 For the
newer dry scrub, there was a notice-
able decrease in CFUs measured after
2 hours with a 3-minute rub com-
pared with a 30-second rub; how-
ever, there was no difference between
a 3-minute rub and a 5-minute rub.
Although these results are helpful in
assessing general concepts of antisep-
sis, these studies have limited clinical
implications because they used CFUs
rather than SSIs as the end point.
Significance of Study End
Points: CFUs Versus
Infection Rates
In analyzing the current data on mul-
tiple factors and their influence on
SSI, it is important to recognize the
two major end points used in studies.
The most reliable outcome measure
is the actual rate of SSI. However,
many studies use the surrogate end
point of CFUs or bacterial counts,
based on the assumption that these
values correlate directly with rates of
SSI. This assumption is incorrect.
Multiple studies have shown that SSI
rates may differ even when CFUs are
equivalent and, conversely, that
CFUs may differ when SSI rates are
equivalent.5,6,8 It is important to keep
this factor in mind when evaluating
the clinical significance of a particu-
lar study.
Surgical Site Skin
Preparation
Proper preoperative skin preparation
is of utmost importance in reducing
the rate of SSI. Approximately two
thirds of all SSIs are confined to the
96
surgical incision site.1 Endemic skin
bacterial flora, such as gram-positive
bacteria, account for most such in-
fections. Gram-positive bacterial
growth is 2.5 times higher than
gram-negative bacterial growth.1
Ellenhorn et al6 studied the appli-
cation of a disinfecting agent to de-
termine whether the mechanical act
of scrubbing the skin was beneficial.
In their randomized controlled trial
of 234 patients, subjects were pre-
pared either with a 5-minute scrub
using povidone-iodine followed by a
paint with povidone-iodine or with
povidone-iodine paint alone.6 The
rate of SSI was 10% in both groups.
However, more CFUs were found on
the skin in patients prepared with
scrub and paint than in the patients
prepared with paint alone. The in-
creased number of CFUs in patients
prepared with scrub and paint is be-
lieved to be secondary to increased
irritation of the skin and subsequent
release of resident microbes.6 Even
so, CFUs are not necessarily related
to SSIs, and the authors of the study
concluded that scrubbing was not of
added benefit in antisepsis.
Selecting an Antiseptic
Agent
In 2007, Digison2 published the re-
sults of a comparison of various
agents used in preoperative skin
preparation, including povidone-
iodine, alcohol, and chlorhexidine.
Chlorhexidine was more effective
than the other agents in preventing
catheter-related blood infections, and
it provided longer-lasting effects.
Chlorhexidine in combination with
alcohol proved to be the most effec-
tive agent overall.
Another agent commonly used in
skin preparation is the combination
of an iodine-based compound, iodine
povacrylex, with alcohol. In 2009,
Swenson et al9 reported the out-
comes of three different preparation
Journal of the American Academy of Orthopaedic Surgeons
protocols implemented sequentially
in 3,209 general surgery procedures
performed at a single institution. The
rate of SSI was 4.8% for both
povidone-iodine and iodine pov-
acrylex preparations, compared with
a rate of 8.2% for chlorhexidine.
These results suggest not only that
iodine-based preparations are more
effective than chlorhexidine but also
that the addition of alcohol to an
iodine-based preparation has little
added benefit. Unfortunately, these
data may be biased by the signifi-
cantly higher percentage of dirty
wounds included in the group pre-
pared with chlorhexidine (15.6%)
versus 8.7% in the povidone-iodine
group and 3.9% in the iodine pov-
acrylex group.9
A randomized controlled trial pub-
lished in 2010 clearly demonstrates
the increased efficacy of chlorhexi-
dine. Darouiche et al1 conducted a
prospective randomized trial from
2004 to 2008 in six university-
affiliated hospitals in the United
States. In this study, 849 patients
were randomly divided into two
groups. One group of patients under-
went preoperative skin preparation
using a solution composed of 2%
chlorhexidine gluconate with 70%
isopropyl alcohol. The other group
was prepared with an aqueous
povidone-iodine solution. The end
point studied was SSI within 30 days
postoperatively. A significant de-
crease in the number of SSIs was
noted with the chlorhexidine solu-
tion compared with povidone-iodine
(9.5% and 16.1%, respectively),
which is equivalent to a relative risk
of 0.59 with chlorhexidine versus
povidone-iodine.
Neurotoxicity of Chlorhexidine
Chlorhexidine is not used as exten-
sively as povidone-iodine in cranial
and spine surgery because chlorhexi-
dine currently is not approved for
procedures in which the meninges

are contacted or exposed. Two early
animal studies and a series of case re-
ports serve as the foundation for this
recommendation.10 Although these
studies demonstrate that the degree
of neuronal damage is proportional
to the concentration of chlorhexidine
exposure, they also show that dam-
aged nerves do regenerate. In the rat
model, 2 weeks after direct contact
with chlorhexidine 0.1% solution,
adrenergic nerves had almost com-
pletely regenerated. At nearly 2
months (51 days) following dosing
with chlorhexidine 1.5% solution,
40% of normal adrenergic nerve
plexus had reformed. Also, when
ethanol was added to the solutions,
no additional degenerative effect was
noted.10 Thus, although chlorhexi-
dine has been reported to have a
neurodegenerative side effect, such
effects occur only at high concentra-
tions, and they are reversible to a de-
gree over time.
Toxicity of Povidone-iodine
Similar animal studies have been per-
formed using povidone-iodine. Al-
though Jiang et al11 did not directly
analyze the result of this chemical on
neurons, they demonstrated severe
epithelial damage at concentrations
>2.5% and significant corneal edema
at concentrations >1.5%. Povidone-
iodine, like chlorhexidine, demon-
strates dose-dependent levels of tox-
icity.
Clinical Significance of Animal
Studies
At one institution, the preprocedural
preparation for lumbar drain placement
was changed from an iodine-based
agent to a chlorhexidine solution; no
adverse events were noted in a 60-
month period after that change.12
The authors of an earlier randomized
controlled trial compared chlorhexi-
dine-impregnated sponge dressings
with plain sponge dressings in 57 pa-
tients with indwelling epidural cathe-
February 2012, Vol 20, No 2
ters.13 No adverse neurologic se-
quelae were noted with the
chlorhexidine-impregnated dressing.
Such reports suggest lack of clinically
significant neurotoxicity when the
nervous system is exposed to low
concentrations of chlorhexidine.
Adhesive Incision Drapes
Plastic adhesive drapes are com-
monly applied after skin preparation
to help preserve a barrier between
the skin and the surgical field.
Drapes impregnated with antiseptic
agents, such as iodophor, are also
available. Although the use of such
drapes is theoretically sound, it has
not been shown to reduce SSIs.
A Cochrane review of 3,082 pa-
tients analyzed SSI rates with and
without the use of adhesive drapes.14
Application of adhesive drapes was
associated with an SSI rate of 13.4%
compared with a rate of 11.2% in
patients who were not prepared with
such drapes. Two of the studies in-
cluded in the analysis specifically
compared iodophor-impregnated ad-
hesive drapes with no drape. SSIs
were noted in 6.8% of patients on
whom draping was used and in
6.5% of the control group. In a se-
ries of 616 anterior cervical fusions,
no SSIs occurred even though
iodophor-impregnated adhesive
drapes were not used in any case.15
Preoperative Hair Shaving
Hair shaving is another practice that
may be more of a tradition than an
appropriate part of preoperative
preparation. Beginning in the 1800s,
hair removal was believed to be ben-
eficial because it facilitated skin
marking, clarified orientation for the
surgeon, expedited closure, and
seemingly had the potential for re-
ducing the risk of infection. How-
ever, microtrauma from hair shaving
has been felt to increase bacterial
colonization, and shaving adds to the
James S. Harrop, MD, et al
length of surgery, thereby indirectly
increasing the rate of infection.16
A 10-year prospective study of
62,939 surgical wounds demon-
strated an infection rate of 0.9%
with no shaving compared with
1.4% with an electric razor and
2.5% with a manual razor.17 In a
2001 cohort study of 1,038 Turkish
patients, the infection rate was
1.22% in persons whose heads were
shaved preoperatively and 1.25% for
those whose heads were not
shaved.18 A 1992 study of patients in
the United States19 and a 2001 study
of patients in the United Kingdom8
showed no difference between these
two methods. In 2001, researchers at
the Medical University of South Car-
olina conducted a retrospective study
of 250 patients treated in a 2.5-year
period and found no difference in ei-
ther infection rates or severity of in-
fections regardless whether patients
were shaved preoperatively.16 A ran-
domized controlled study published
in 2007 involving 789 spine patients
in Istanbul showed that shaving may
increase the rate of SSIs. The rate of
SSI was 0.23% in patients who were
not shaved and 1.07% in those who
were shaved.20
Operating Room Behavior
Strict adherence to the basic princi-
ples of sterile technique may be the
most important factor in preventing
SSIs. A study published in 2009 ana-
lyzed multiple factors of operating
room behavior and their respective
effects on infection rates in general
surgery procedures.21 The analysis
involved 1,032 observations for
which the primary end point was SSI
rates for either standard antiseptic
protocol or extensive antiseptic mea-
sures. Extensive measures included
frequent changing of gloves, use of
surgical caps that covered the sur-
geons’ ears and necks, use of an
97
Contributing Factors to Surgical Site Infections
Table 1
Components of the Discipline
Score
Violations in sterile technique
Skin preparation/surgical draping
Hand washing
Proper attire
Distance of 50 cm maintained by non-
sterile persons
Exchange of surgical team members
Movement in the operating room
Operating room noise
Visitors
Intraoperative changing of patient posi-
tion
Adapted with permission from Beldi G,
Bisch-Knaden S, Banz V, Mühlemann K,
Candinas D: Impact of intraoperative
behavior on surgical site infections. Am J
Surg 2009;198(2):157-162.
iodine-impregnated adhesive incision
drape, and copious irrigation with
lactated Ringer solution. No signifi-
cant difference was found between
the two protocols. The infection rate
was 15% with extensive antisepsis
and 14% with the standard protocol.
A second purpose of this study was
to determine the impact of particular
factors on SSIs.21 A discipline score
was generated for each case (Table
1). A score greater than zero was as-
sociated with a 2.02 odds ratio for
SSIs. The four factors that had a par-
ticular impact on SSIs were exchange
of surgical team members (relative
risk, 2.837), movement in the oper-
ating room (relative risk, 1.819), op-
erating room noise (relative risk,
1.866), and the presence of visitors
(relative risk, 1.789). The increase in
SSIs attributable to operating room
behavior is secondary to multiple mi-
nor violations in sterile technique
rather than to a single gross contami-
nation. Scores were ≤3 in most cases.
Aside from a discipline score greater
than zero, factors that played the
largest role in increasing the risk
of SSIs were body mass index
>30kg/m2, surgeon experience, and
98
duration of surgery. Overall, intraop-
erative factors are more significant
risk factors for SSIs than are patient-
related factors.
Wound Irrigation
Wound irrigation with normal saline
or with saline containing bacitracin
or an antibiotic is another common
practice. Unfortunately, much of the
existing literature pertains to the ef-
fectiveness of different types of irri-
gation for irrigation and débride-
ment of infected wounds, and the
reported data cannot be extrapolated
to determine their effectiveness in
preventing SSIs. In some of the appli-
cable studies, no difference has been
noted in SSI rates with or without
routine irrigation,21 whereas in oth-
ers, decreased infection rates have
been reported with routine irriga-
tion.22 Similarly, some studies indi-
cate no significant changes in SSIs
with antibiotic irrigation,22 whereas
others demonstrate marked reduc-
tions in infection rates with this mea-
sure.23 The effectiveness of irrigation
in reducing SSIs remains unclear.
Surgical Duration
Surgical duration is directly related
to infection rates. Specifically, surgi-
cal duration above the 75th percen-
tile has been shown to be an inde-
pendent risk factor for SSI, and
surgical duration >3 hours is associ-
ated with an odds ratio of 3.34 for
SSIs in patients undergoing general
surgical procedures.21 This finding is
in line with other reports in the liter-
ature showing that surgical duration
>2 hours is an independent risk fac-
tor for SSI in both orthopaedic and
general surgical patients.24 In 2010,
Procter et al24 published their find-
ings of a prospective systematic
study involving 299,359 operations
in 173 hospitals. They analyzed the
Journal of the American Academy of Orthopaedic Surgeons
number of infectious complications
that occurred within 30 days and
were related to surgical duration;
these authors found that the risk of
infection increased 2.5% and that
the odds ratio increased by 0.32 for
every 30 minutes of surgery (Figure
1). With surgery lasting <1 hour, the
rate of any infection was 3.7%; this
rate increased to 31.4% with surgery
lasting >6 hours.
The correlation between surgical
time and rate of SSI is thought to be
attributable to increased exposure to
airborne pathogens, considerable
surgical trauma, and increased op-
portunities for violations in sterile
technique.24 In 2008, Dalstrom et al25
published the results of a study com-
paring contamination rates of sterile
trays in rooms with no traffic with
those of sterile trays in rooms with
traffic. Although contamination
rates were time-dependent, there was
no difference between the two
groups. In addition, no contamina-
tion was noted for trays that were
opened and subsequently covered
with a sterile surgical towel. Longer
surgical time also results in increased
periods of tissue retraction, resulting
in increased tissue ischemia, necrosis,
and desiccation.24 Frequent release of
tension on self-retractors and fre-
quent irrigation of the wound may
help minimize tissue necrosis and re-
duce the risk of wound infections.24
Patients subject to extended proce-
dures also may be more susceptible
to intraoperative hypothermia,
which has been shown to be an inde-
pendent risk factor for SSIs.24
Patient-related Risk
Factors
Patient-related risk factors appear to
play a lesser role than do intraopera-
tive factors in rates of SSI.21 Preexist-
ing diabetes mellitus is an indepen-
dent risk factor for SSI because it is
 James S. Harrop, MD, et al

Figure 1 surface antiseptics have limited effi-

cacy in eradicating MRSA in patients
colonized at multiple sites; these pa-
tients may require multiple decoloni-
zation courses in addition to oral an-
tibiotics.38,39 Moreover, the long-term
efficacy of topical decolonization is
questionable.40 Gilpin et al41 reported
that decolonization had the greatest
effect at 30 to 60 days and dimin-
ished thereafter. Specifically, throat
colonization, mupirocin resistance,
and age ≥80 years were factors sig-
nificantly associated with failure of
decolonization.

Summary

Impact of surgical duration on the rate of postoperative infections. Antisepsis is an important part of
UTI = urinary tract infection. (Adapted with permission from Procter LD, perioperative care. Hand washing is
Davenport DK, Bernard AC, Zwischenberger JB: General surgical operative critical in reducing infection rates.5,7
duration is associated with increased risk-adjusted infectious complication Dry scrub has been shown to be as
rates and length of hospital stay. J Am Coll Surg 2010;210[1]:60-65.)
effective as traditional scrub, and
preoperative scrubbing lasting >3
associated with impaired wound reduce the transmission of the patho- minutes provides no added benefit.
healing.26 Obesity has also been asso- gen; however, studies have failed to New agents, such as chlorhexidine,
ciated with increased risk of superfi- demonstrate their benefit and have seem to be more effective than tradi-
cial SSI27,28 because of the amount of instead reinforced the importance of tional povidone-iodine, and reported
dead space created during surgical hand washing alone.34 neurotoxicity of this agent has not
wound closure and associated local The value of preoperative MRSA been shown to be clinically signifi-
fat necrosis.29 History of prior SSI screening on admission and adminis- cant in animal studies. Furthermore,
also markedly increases the risk of tration of MRSA-specific prophylac- current literature has demonstrated
SSI during subsequent surgeries, re- tic antibiotics during elective proce- that measures such as contact-
gardless whether the patient has an dures is questionable; nevertheless, precaution gowns, adhesive incision
active infection.26,27 higher rates of SSIs have been noted drapes, and preoperative hair shav-
Methicillin-resistant Staphylococ- in patients colonized with MRSA.30 ing seem to have a limited effect on
cus aureus (MRSA) colonization in- Control and prevention may be reducing SSI rates. However, factors
creases the risk of MRSA infection achieved by decolonizing patients that have been shown to contribute
for the patient and increases the risk who have tested positive for to reducing the occurrence of SSIs in-
of spreading the infection to other MRSA.33 The use of antiseptics (eg, clude shorter surgical time, covering
patients and hospital staff.30 Har- chlorhexidine) for decolonization equipment whenever possible, pre-
barth et al31 reported that 57% of has been shown to be beneficial in venting intraoperative hypother-
patients developed MRSA after hos- reducing infection rates.32,33 Specifi- mia,24 and limiting repetitive minor
pital admission, which indicates a cally, patient-directed preoperative breaches in sterile technique.
high transmission rate from within skin preparation with chlorhexidine Patient-related risk factors such as
the facility. The mainstay of infection wipes before knee and hip arthro- diabetes mellitus, obesity, prior his-
control is prompt identification of plasty has been shown to reduce SSI tory of SSI, and MRSA colonization
MRSA-colonized patients and subse- in case series.35,36 However, limited may increase the risk of SSIs, but
quent enforcement of contact pre- evidence exists for complete eradica- they do not appear to play as signifi-
cautions.32,33 Increasingly, contact- tion, and there are concerns of cant a role as perioperative factors.
precaution gowns are being used to emerging resistances.37 Furthermore, Although these patient-related risk

February 2012, Vol 20, No 2 99

Contributing Factors to Surgical Site Infections
factors may not translate directly to
orthopaedic or neurosurgical pa-
tients in particular, it is reasonable to
assume that factors related to operat-
ing room protocols are applicable to
all surgical specialties.
Innumerable factors may affect or
historically have been thought to af-
fect SSI rates. As more objective data
continue to emerge, surgeons must
be ready to adjust protocols and re-
assess perioperative routines that are
done simply out of habit. To provide
the highest level of patient care in an
efficient manner, orthopaedic sur-
geons must understand the current
evidence regarding the factors that
affect the rates of SSI and implement
techniques to reduce or eliminate
them.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 1,
4-7, 20, 21, 25, 30, 31, 34, and
38-40 are level I studies. References
3, 9, 12, 13, 17, 27, 29, 37, and 41
are level II studies. References 15,
22-24, 26, and 28 are level III stud-
ies. References 2, 8, 35, and 36 are
level IV studies. References 10, 11,
32, and 33 are level V expert opin-
ion.
References printed in bold type indi-
cate those published within the past
5 years.
1. Darouiche RO, Wall MJ Jr, Itani KM,
et al: Chlorhexidine-alcohol versus
povidone-iodine for surgical-site
antisepsis. N Engl J Med 2010;362(1):
18-26.
2. Digison MB: A review of anti-septic
agents for pre-operative skin
preparation. Plast Surg Nurs 2007;27(4):
185-189.
3. Guzel A, Ozekinci T, Ozkan U, Celik Y,
Ceviz A, Belen D: Evaluation of the skin
flora after chlorhexidine and povidone-
iodine preparation in neurosurgical
practice. Surg Neurol 2009;71(2):207-
210.
100
4. Farrington RM, Rabindran J, Crocker G,
Ali R, Pollard N, Dalton HR: ‘Bare
below the elbows’ and quality of hand
washing: A randomised comparison
study. J Hosp Infect 2010;74(1):86-88.
5. Tanner J, Swarbrook S, Stuart J: Surgical
hand antisepsis to reduce surgical site
infection. Cochrane Database Syst Rev
2008;1:CD004288.
6. Ellenhorn JD, Smith DD, Schwarz RE,
et al: Paint-only is equivalent to scrub-
and-paint in preoperative preparation of
abdominal surgery sites. J Am Coll Surg
2005;201(5):737-741.
7. Parienti JJ, Thibon P, Heller R, et al;
Antisepsie Chirurgicale des mains Study
Group: Hand-rubbing with an aqueous
alcoholic solution vs traditional surgical
hand-scrubbing and 30-day surgical site
infection rates: A randomized
equivalence study. JAMA 2002;288(6):
722-727.
8. Tang K, Yeh JS, Sgouros S: The influence
of hair shave on the infection rate in
neurosurgery: A prospective study.
Pediatr Neurosurg 2001;35(1):13-17.
9. Swenson BR, Hedrick TL, Metzger R,
Bonatti H, Pruett TL, Sawyer RG:
Effects of preoperative skin preparation
on postoperative wound infection rates:
A prospective study of 3 skin
preparation protocols. Infect Control
Hosp Epidemiol 2009;30(10):964-971.
10. Henschen A, Olson L: Chlorhexidine-
induced degeneration of adrenergic
nerves. Acta Neuropathol 1984;63(1):
18-23.
11. Jiang J, Wu M, Shen T: The toxic effect
of different concentrations of povidone
iodine on the rabbit’s cornea. Cutan
Ocul Toxicol 2009;28(3):119-124.
12. Greenberg BM, Williams MA: Infectious
complications of temporary spinal
catheter insertion for diagnosis of adult
hydrocephalus and idiopathic
intracranial hypertension. Neurosurgery
2008;62(2):431-435.
13. Shapiro JM, Bond EL, Garman JK: Use
of a chlorhexidine dressing to reduce
microbial colonization of epidural
catheters. Anesthesiology 1990;73(4):
625-631.
14. Webster J, Alghamdi AA: Use of plastic
adhesive drapes during surgery for
preventing surgical site infection.
Cochrane Database Syst Rev 2007;4:
CD006353.
15. Chin KR, London N, Gee AO, Bohlman
HH: Risk for infection after anterior
cervical fusion: Prevention with
iodophor-impregnated incision drapes.
Am J Orthop (Belle Mead NJ) 2007;
36(8):433-435.
16. Miller JJ, Weber PC, Patel S, Ramey J:
Intracranial surgery: To shave or not to
Journal of the American Academy of Orthopaedic Surgeons
shave? Otol Neurotol 2001;22(6):908-
911.
17. Cruse PJ, Foord R: The epidemiology of
wound infection: A 10-year prospective
study of 62,939 wounds. Surg Clin
North Am 1980;60(1):27-40.
18. Bekar A, Korfali E, Doğan S, Yilmazlar
S, Başkan Z, Aksoy K: The effect of hair
on infection after cranial surgery. Acta
Neurochir (Wien) 2001;143(6):533-536.
19. Winston KR: Hair and neurosurgery.
Neurosurgery 1992;31(2):320-329.
20. Celik SE, Kara A: Does shaving the
incision site increase the infection rate
after spinal surgery? Spine (Phila Pa
1976) 2007;32(15):1575-1577.
21. Beldi G, Bisch-Knaden S, Banz V,
Mühlemann K, Candinas D: Impact of
intraoperative behavior on surgical site
infections. Am J Surg 2009;198(2):157-
162.
22. Hayashi T, Shirane R, Yokosawa M,
Kimiwada T, Tominaga T: Efficacy of
intraoperative irrigation with saline for
preventing shunt infection. J Neurosurg
Pediatr 2010;6(3):273-276.
23. Parcells JP, Mileski JP, Gnagy FT,
Haragan AF, Mileski WJ: Using
antimicrobial solution for irrigation in
appendicitis to lower surgical site
infection rates. Am J Surg 2009;198(6):
875-880.
24. Procter LD, Davenport DL, Bernard AC,
Zwischenberger JB: General surgical
operative duration is associated with
increased risk-adjusted infectious compli-
cation rates and length of hospital stay.
J Am Coll Surg 2010;210(1):60-65,
e1-e2.
25. Dalstrom DJ, Venkatarayappa I,
Manternach AL, Palcic MS, Heyse BA,
Prayson MJ: Time-dependent
contamination of opened sterile
operating-room trays. J Bone Joint Surg
Am 2008;90(5):1022-1025.
26. Wimmer C, Gluch H, Franzreb M, Ogon
M: Predisposing factors for infection in
spine surgery: A survey of 850 spinal
procedures. J Spinal Disord 1998;11(2):
124-128.
27. Andreshak TG, An HS, Hall J, Stein B:
Lumbar spine surgery in the obese
patient. J Spinal Disord 1997;10(5):376-
379.
28. Patel N, Bagan B, Vadera S, et al:
Obesity and spine surgery: Relation to
perioperative complications. J Neurosurg
Spine 2007;6(4):291-297.
29. Debarge R, Nicolle MC, Pinaroli A, Ait
Si Selmi T, Neyret P: Surgical site
infection after total knee arthroplasty: A
monocenter analysis of 923 first-
intention implantations [French]. Rev
Chir Orthop Reparatrice Appar Mot

2007;93(6):582-587.
30. Akins PT, Belko J, Banerjee A, et al:
Perioperative management of
neurosurgical patients with methicillin-
resistant Staphylococcus aureus.
J Neurosurg 2010;112(2):354-361.
31. Harbarth S, Fankhauser C, Schrenzel J,
et al: Universal screening for methicillin-
resistant Staphylococcus aureus at
hospital admission and nosocomial
infection in surgical patients.
JAMA 2008;299(10):1149-1157.
32. Calfee DP, Salgado CD, Classen D, et al:
Strategies to prevent transmission of
methicillin-resistant Staphylococcus
aureus in acute care hospitals. Infect
Control Hosp Epidemiol 2008;29(suppl
1):S62-S80.
33. Coia JE, Duckworth GJ, Edwards DI,
et al; Joint Working Party of the British
Society of Antimicrobial Chemotherapy;
Hospital Infection Society; Infection
Control Nurses Association: Guidelines
for the control and prevention of
meticillin-resistant Staphylococcus
aureus (MRSA) in healthcare facilities.
J Hosp Infect 2006;63(suppl 1):S1-S44.
34. Snyder GM, Thom KA, Furuno JP, et al:
February 2012, Vol 20, No 2
View publication stats
Detection of methicillin-resistant
Staphylococcus aureus and vancomycin-
resistant enterococci on the gowns and
gloves of healthcare workers. Infect
Control Hosp Epidemiol 2008;29(7):
583-589.
35. Johnson AJ, Daley JA, Zywiel MG,
Delanois RE, Mont MA: Preoperative
chlorhexidine preparation and the
incidence of surgical site infections after
hip arthroplasty. J Arthroplasty 2010;
25(6 suppl):98-102.
36. Zywiel MG, Daley JA, Delanois RE,
Naziri Q, Johnson AJ, Mont MA:
Advance pre-operative chlorhexidine
reduces the incidence of surgical site
infections in knee arthroplasty. Int
Orthop 2011;35(7):1001-1006.
37. Loveday HP, Pellowe CM, Jones SR,
Pratt RJ: A systematic review of the
evidence for interventions for the
prevention and control of meticillin-
resistant Staphylococcus aureus (1996-
2004): Report to the Joint MRSA
Working Party (Subgroup A). J Hosp
Infect 2006;63(suppl 1):S45-S70.
38. Simor AE, Phillips E, McGeer A, et al:
Randomized controlled trial of
chlorhexidine gluconate for washing,
James S. Harrop, MD, et al
intranasal mupirocin, and rifampin and
doxycycline versus no treatment for the
eradication of methicillin-resistant
Staphylococcus aureus colonization. Clin
Infect Dis 2007;44(2):178-185.
39. Harbarth S, Dharan S, Liassine N,
Herrault P, Auckenthaler R, Pittet D:
Randomized, placebo-controlled,
double-blind trial to evaluate the efficacy
of mupirocin for eradicating carriage of
methicillin-resistant Staphylococcus
aureus. Antimicrob Agents Chemother
1999;43(6):1412-1416.
40. Wendt C, Schinke S, Württemberger M,
Oberdorfer K, Bock-Hensley O, von
Baum H: Value of whole-body washing
with chlorhexidine for the eradication of
methicillin-resistant Staphylococcus
aureus: A randomized, placebo-
controlled, double-blind clinical trial.
Infect Control Hosp Epidemiol 2007;
28(9):1036-1043.
41. Gilpin DF, Small S, Bakkshi S, Kearney
MP, Cardwell C, Tunney MM: Efficacy
of a standard methicillin-resistant
Staphylococcus aureus decolonisation
protocol in routine clinical practice.
J Hosp Infect 2010;75(2):93-98.
101