Infectious Diseases, 2015; Early Online: 1–7

Original article

Surgical site infections after abdominal surgery: incidence and

risk factors. A prospective cohort study

Aga Emil1,2, Keinan-Boker Lital2,3, Arieh Eithan4, Mais Tamar4,

Rabinovich Alia4, Nassar Faris5,6

From the 1Western Galilee Medical Center, Infection Control, Nahariya, 2School of Public Health, Faculty of Welfare and
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15

Health Sciences, University of Haifa, Haifa, 3Israel Center for Disease Control, Ministry of Health, Ramat-Gan,
4Department of Surgery and 5Department of Medicine ‘E’, Western Galilee Medical Center, Nahariya, and
6Faculty of Medicine in the Galilee, Bar Ilan University, Safed, Israel

Abstract
Background: Abdominal surgeries have high rates of surgical site infections (SSIs), contributing to increased morbidity and
mortality and costs for hospitalization. The aim of this study was to determine the SSI incidence rates and risk factors after
abdominal surgeries. Methods: This prospective cohort study included all patients undergoing abdominal surgeries between
For personal use only.

2005 and 2007 in the Western Galilee Medical Center in Nahariya, Israel. SSI incidence rates were calculated per 100
operations. Odds ratios (ORs) were estimated for each risk factor using univariate and multivariate analyses by logistic
regression models. Results: Among 302 patients in the study cohort, the total SSI incidence rate was 22.2%. The univariate
analysis defined 13 variables significantly associated with SSI: age  60 years, lower functional status, diabetes mellitus,
congestive heart failure, immunocompromising underlying disease, treatment with chemotherapy and other immunosup-
pressive medications, impaired immune system open cholecystectomy, laparotomy, an American Society of Anesthesiologists
(ASA) score  2, drain insertion, and ‘dirty wound’ classification. In multivariate regression analysis, treatment with immu-
nosuppressive medications (OR  2.5, 95% confidence interval (CI)  1.099–143.443), open cholecystectomy (OR  2.25,
95% CI  2.242–40.109), and dirty wound classification (OR  2.179, 95% CI  3.80–20.551) were significantly associated
with SSI. Conclusions: The significant risk factors defined should be addressed preoperatively to decrease the risk for SSI.
Wound surveillance in the post-discharge period is necessary for correct estimation of SSI rates.

Keywords: Surgical site infection; SSI; abdominal surgery; dirty wound

Introduction
Surgical site infections are common hospital-acquired
infections (HAIs) and are associated with high mor-
bidity and mortality [1]. It has been estimated that
each patient with a surgical site infection (SSI) requires
at least an additional 6 days of hospitalization, thus
doubling hospital care costs [2]. Specifically, abdomi-
nal surgeries have been found as an independent risk
factor associated with high incidence of SSI [3].
Bacterial concentrations are high in the intestines and
abdominal operations are more likely than others to
involve bacterial contamination. The incidence rate of
SSIs was 20% or more in studies following patients
into the post-discharge period [3].
SSI is associated with numerous patient-related
and procedure-related risk factors that differ in their
effect on the SSI rates. The patient-related factors
include: advanced age, malnutrition, diabetes mel-
litus, smoking, morbid obesity, remote body site
infection, and impaired immune system as defined
by the presence of malignant disease, immunosup-
pressive treatment (chemotherapy, cytotoxic agents,
steroids, other immunosuppressive medications such
as cyclosporine A). Additional risk factors for SSI
are long preoperative hospital stay and an ASA
score  2 (patient physical status as defined by the
American Society of Anesthesiologists) [3]. The
procedure-related risk factors include: long duration

Correspondence: Emil Aga, 46\2 Kihelat Yahadut Zarfat St, PO Box 8373, Maalot-Tarshiha, Israel. Tel:  972 507887858. Fax:  972 49107280.
E-mail: emil.aga@naharia.health.gov.il

(Received 28 December 2014; accepted 19 May 2015)

ISSN 2374-4235 print/ISSN 2374-4243 online © 2015 Informa Healthcare
DOI: 10.3109/23744235.2015.1055587
 2 A. Emil et al.
of surgery, the quality of patient skin preparation,
preoperative hair removal (i.e. clipping vs shaving of
the surgical site), prophylactic administration of
antimicrobial agents, operating room ventilation,
inadequate sterilization of surgical instruments, for-
eign material at the surgical site, surgical drains,
surgical techniques, urgent as opposed to non-ur-
gent surgery, improper surgical team hand prepara-
tion, and surgical wound class [1–8]. Previous
studies have documented that diabetes mellitus is
associated with a 1.5–2.5- or even 4.9-fold increased
risk for SSI [9–11]. Nicotine use delays primary
wound healing by increasing tissue hypoxia and
causing local and systemic vasoconstriction and may
multiply the risk of SSI by 3.1-fold [11].
Insertion and prolonged presence of a surgical
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15
drain for 5–16 days or for  16 days was associated
with 1.84- and 2.14-fold increased risk, respectively
[10]. A multivariate analysis showed that age, wound
contamination class, ASA score, and surgery dura-
tion were independent risk factors for all selected
procedures [10,11].
The classification of surgical wounds based on
the degree of microbial contamination demonstrates
that abdominal SSI rates range between 2% after
For personal use only.
‘clean’ surgery, to 4–10% for ‘clean-contaminated’
surgery, and  10% for ‘contaminated’ surgery, and
can reach  20% in the ‘dirty’ surgery category [12].
Even higher rates are reported by prospective studies
in developing countries [13]. A longer duration, even
of a clean operation, represents increased time at risk
for contamination [1].
The aim of the present study was to determine
the SSI rates after abdominal surgery and to assess
the risk factors for SSI in a cohort of patients under-
going abdominal surgery.
At the Western Galilee Medical Center in
Naharia no active surveillance has been carried out
in relation to SSI, in spite of its significance and
importance. This is the first study in our institution
attempting to evaluate the incidence of SSI in
abdominal surgery and the risk factors involved.
Materials and Methods
Study design and study population
This was a prospective cohort study. The target pop-
ulation consisted of all patients undergoing abdomi-
nal surgery in the Western Galilee Medical Center.
The survey population included all patients, aged
15 years and older, undergoing abdominal surgeries
during two periods between 2005 and 2007 in the
General Surgical Department A in the Western Gal-
ilee Medical Center in Nahariya. Abdominal surger-
ies included in this study were appendectomy, bile
duct surgery, cholecystectomy, colon resection, her-
nia repair, abdominal injury repair, abdominal tumor
resection; esophageal, stomach, liver, pancreatic, and
colorectal operations; and laparotomies.
Data collection and study tools
Data were collected in two non-successive periods
between November 1, 2005 and April 30, 2006; and
between April 1, 2007 and August 30, 2007, to
achieve a sufficient study size. No significant differ-
ences were observed in the data collected from both
periods. Following the approval of the Institutional
Review Board (‘Helsinki’ committee) of the Western
Galilee Medical Center for the proposed study, rel-
evant data were collected, including: medical and
nursing charts, doctors’ reports, and telephone inter-
views with patients after discharge. Most infections
manifest after discharge and often patients with
infections never return to the hospital where surgery
was performed, while traditional inpatient surveil-
lance methods are not sufficient. Thus, clinic appoint-
ment follow-up and a telephone questionnaire were
used to collect relevant data after hospital discharge.
The telephone questionnaire included details to
assess whether a patient had an SSI or not. The
assessment of SSI incidence was based on the CDC
criteria for SSI and the National Nosocomial Infec-
tions Surveillance (NNIS) definitions [8]. Diagnosis
of an SSI was done by the surgeons during hospital-
ization following the operation or during the re-
hospitalization period (if applicable), or when patients
were seen in the hospital surgical clinic within the
first month after surgery, or by community general
practitioners.
Data analysis
Personal and other characteristics of patients devel-
oping an SSI were compared to those who did not,
and tested for significance by the chi-squared test
(for discrete variables) or t test for independent sam-
ples (for continuous variables). Some of the variables
were grouped into larger categories to allow com-
parison when numbers were small. For example, the
wounds were classified into the following categories:
clean, clean-contaminated, contaminated, and dirty.
The incidence and 95% confidence interval (CI)
of SSI per 100 operations was calculated.
Univariate logistic regression models provided esti-
mates (odds ratio, OR, and 95% CI) of the effect of
each risk factor on the outcome. A multivariate logistic
regression model for the significant risk factors identi-
fied in the univariate model provided risk estimates for
SSI adjusted for potential confounders, such as diabe-
tes, duration of surgery, smoking status, and others.

All statistical analyses were performed using the
SPSS version Windows program A (SPSS Inc.,
Chicago, IL, USA). A significance level of p  0.05
was defined for all tests and the CI was set at 95%.
Results
In total, 328 patients were eligible for the study and
302 (92%: 53% males, 47% females) agreed to par-
ticipate and had adequate follow-up (response
rate  95.2%). Of these 302 participants, 67 (22.1%)
developed SSI up to 30 days post surgery. Seven
patients that had not yet developed an SSI (30 days
post surgery) were lost to follow-up. Most patients
were  60 years old (183, 62%) and non-smokers
(222, 76%). A total of 275 (92%) had a fully inde-
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15
Surgical site infections after abdominal surgery  3
systemic steroid therapy or other immunosuppressive
medications were not common, 1.7%, 3.4%, and
1.3%, respectively. Only 17 (5.6%) participants were
defined as having an impaired immune system.
In all, 57% of patients had emergency surgeries.
A drain was inserted in 62.8%. Surgery duration was
120 min or longer in 40 (14.7%) patients. Antimi-
crobial prophylaxis was administered before or dur-
ing the operation in 277 (90%) patients. The ASA
score was 3–5 in 59 (20.7%) patients. Laparotomy
was the most common type of surgery and accounted
for 104 (34.6%) operations.
The least frequent type of surgery was open
cholecystectomy, with only 22 (7.3%) procedures.
In all, 167 wounds (57.4%) were defined as clean,
82 (28.2%) as clean contaminated, 17 (5.8%) as

pendent functional status, and only 24 (8%) required
nursing care or were partially dependent.
Thirty-nine participants (13.2%) had diabetes
mellitus. A similar number (13.4%) had congestive
heart failure, and 64 (21.6%) had a malignant disease.
The majority (95%) of the study participants had no
other immunocompromising disease. Chemotherapy,
contaminated, and 25 (8.6%) as dirty.
Patients who developed an SSI were older than
those who did not: 49.3% of patients  60 years old
developed SSI compared with 35.2% in the group
  60 years of age. The rates of ‘functionally dependent’
(15.2%) and ‘functional partially dependent’ patients
(3.0%) were higher in the group that developed SSI

Table I. Univariate analysis of differences between patients with (SSI) and without (SSI) surgical site infections regarding demographics,
For personal use only.

underlying morbidity, and current medication.

SSI (%), SSI (%),

Variable Categories n  67 n  234 p value, c² OR Lower CI Upper CI

Gender Malea 62.7 50.7 0.083 1.465 0.945 2.271

Female 37.3 49.3
Age (years)  60a 49.3 35.2 0.038 1.558 1.026 2.366
 60 50.7 64.8
Smoking In the pasta 4.6 6.7 0.905 1.116 0.690 1.806
Currentlya 18.2 16.4
Never smoked 74.2 76.9
Functional status Nursing carea 15.2 3.9 0.002 2.546 1.598 4.058
Partially dependenta 3.0 1.3
Independent 81.8 94.8
Diabetes mellitus Noa 78.1 89.2 0.021 1.838 1.129 2.993
Yes 21.9 10.8
Chronic pulmonary disease Noa 95.4 93.4 0.561 0.739 0.257 2.125
Yes 4.6 6.6
‎Congestive heart failure‫‏‬ Noa 77.3 89.4 0.011 1.908 1.197 3.042
Yes 22.7 10.6
Past or current cancer Noa 69.8 80.7 0.064 1.565 0.987 2.483
Yes 30.2 19.3
Other immunocompromising disease Noa 89.7 97.2 0.014 2.471 1.335 4.574
Yes 10.3 2.8
Malnutrition Noa 93.8 95.1 0.665 1.218 0.511 2.902
Yes 6.3 4.9
Chemotherapy Noa 95.5 99.1 0.040 2.781 1.316 5.878
Yes 4.5 0.9
Steroid treatment Noa 93.8 97.4 0.151 1.907 0.864 4.208
Yes 6.3 2.6
Treatment with other Noa 95.5 99.6 0.011 3.480 1.899 6.380
immunosuppressive drugs
Yes 4.5 0.4
Immune status Normala 86.6 96.6 0.002 2.595 1.567 4.289

­CI, confidence interval; OR, odds ratio.

aReference standard.
 4 A. Emil et al.
compared with the group that did not (3.9% and 1.3%,
respectively) (Table I).
Gender and smoking status did not differ signifi-
cantly between the groups.
Significant differences were noted regarding
immunocompromising diseases, chemotherapy, and
treatment with other immunosuppressive medica-
tions (Table I).
Comparison between groups by underlying mor-
bidity and current medication (as seen in Table II)
showed that the frequency of laparotomy was 53.7%
in patients with SSI and 29.1%, in those without.
Open cholecystectomy was more common in patients
with SSI (31.4% vs 2.6%), as well as an ASA score  2
(31.7% vs 17.6%), presence of abdominal drains
(53.6% vs 32.9%), surgery duration  120 min
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15
Significant risk factors identified by the univariate
analysis were included in the multivariate logistic
regression analysis. The results are presented in
Table III. Dirty wound classification (p  0.00,
CI  3.80, 20.55), treatment with other immunosup-
pressive drugs (p  0.042, CI  1.099, 143.446), and
open cholecystectomy (p  0.002, CI  2.242, 40.109),
were significantly associated with development of SSI.
Discussion
The aim of this prospective study was to document
the incidence and the pattern of SSIs up to 30 days
post-surgery in patients undergoing abdominal sur-
gery in the Western Galilee Medical Center, a tertiary

(30.8% vs 10.9%), and dirty wound classification
(27.7% vs 3.11%). Drain insertion was more fre-
quent in patients with SSI (53.6% vs 32.9%).
The univariate analysis revealed 14 variables sig-
nificantly associated with SSI, namely: advanced age
( 60 years), low functional status (requiring nursing
care), presence of diabetes mellitus, congestive heart
failure, immunocompromising underlying disease,
chemotherapy, other immunosuppressive medica-
For personal use only.
care hospital in Northern Israel. The results indicate
a SSI incidence of 22.2%, compatible with previous
reports (around 20%) [3,14]. The main risk factors
identified were dirty wound classification, treatment
with various immunosuppressive medications, and
open cholecystectomy, as demonstrated by the mul-
tivariate logistic regression model.
As revealed in the univariate analysis, advanced
age was a significant risk factor for SSI, which is

tions, an impaired immune system, open cholecys-
tectomy, laparotomy, ASA score  2, drain insertion,
surgery duration  120 min, and dirty wound clas-
sification (Table II). Each of these risk factors was
associated with  1.5-fold increased risk of acquiring
SSI according to the univariate analysis.
compatible with previous reports showing that
patients  60 years had a 1.4–2.6-fold higher risk for
SSI [3]. Advanced age is associated with higher prev-
alence of underlying morbidity, malnutrition,
impaired mobility, limitation in activities of daily liv-
ing, low level of hygiene, and impaired immune

Table II. Univariate analysis of differences between patients with (SSI) and without (SSI) surgical site infection regarding hospitalization,
surgery, and type of surgical wound.

Variable Categories SSI SSI p value OR Lower CI Upper CI

Urgency of surgery Urgenta 58.9 56.8 0.769 1.074 0.667 1.729

Elective 41.1 43.2
Type of surgery Laparotomy 53.7 29.1  0.001 2.200 1.449 3.339
Appendectomy (laparotomy) 20.5 20.5 0.450 0.205 0.987
Appendectomy (open) 4.5 8.1 0.594 0.203 1.739
Hernia 16.7 16.7 0.986 0.557 1.745
Cholecystectomy (open) 13.4 2.6 2.959 1.844 4.747
Cholecystectomy (laparotomy) 3.0 23.1 0.135 0.034 0.533
ASA score  2 68.3 82.4 0.014 1.782 1.140 2.784
 2a 31.7 17.6
Prophylactic antibiotics Noa 11.1 93.8 0.239 0.588 0.230 1.53
Yes 88.9 6.2
Drain insertion No 46.4 67.1 0.004 1.950 1.227 3.099
Yesa 53.6 32.9
Surgery duration  120 min 69.2 89.1  0.001 2.589 1.596 4.201
 120 mina 30.8 10.9
Wound class Clean 27.7 65.9  0.001 4.075 2.853 5.820
Clean-contaminated 32.3 27.0
Contaminated 12.3 4.0
Dirty (infected)a 27.7 3.1

­CI, confidence interval; OR, odds ratio.

aReference standard.
 Surgical site infections after abdominal surgery  5
Table III. Multivariate analysis of risk factors for acquiring surgical site infection (SSI).

Predictor b coefficient Wald statistic Sig. OR Lower CI Upper CI

Age  60 years 0.179 0.190 0.663 1.196 0.534 2.677

Dependency or nursing care functional status 0.334 1.409 0.235 1.396 0.805 2.424
Diabetes mellitus 0.393 0.606 0.436 1.481 0.551 3.977
Congestive heart failure 0.530 1.115 0.291 1.699 0.635 4.543
Drain insertion –0.193 0.187 0.665 0.665 0.343 1.980
Immunosuppressant medication 2.530 4.146 0.042 12.558 1.099 143.446
Chemotherapy 2.311 3.116 0.078 10.084 0.775 131.213
Laparotomy (vs any other surgery) 0.558 1.842 0.175 1.748 0.780 3.914
Cholecystectomy (open) (vs any other surgery) 2.250 9.348 0.002 9.483 2.242 40.109
Dirty wound class (vs clean wound class) 2.179 25.609 0.000 8.837 3.800 20.551

­CI, confidence interval; OR, odds ratio.

system [14–16]. Consequently, the risk for SSI is have identified extended duration of surgery as an
expected to be higher in this group. independent risk factor for SSI [21]. Thus it may
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15

Congestive heart failure affects the perfusion of
peripheral tissues, resulting in slower wound healing
and increasing the risk of SSI [17]. Similarly, our
results showed a significantly higher risk for SSI in
congestive heart failure.
Hyperglycemia has several deleterious effects on
the immune system, most notably impaired function
of neutrophils and mononuclear phagocytes [18].
Diabetes delays wound healing processes and
For personal use only.
serve as a proxy marker for the complexity of the
individual case, for some aspects of the surgical tech-
nique, for prolonged exposure to micro-organisms in
the operating environment, and for diminished effi-
cacy of antimicrobial prophylaxis.
A previous study reported a 2.4-fold higher risk
for SSI in patients with an ASA score  2 [16]. In the
present study, patients with ASA score  2 had a
1.78-fold increased risk for SSI. The aim of an ASA

increases the risk of microbial growth [5]. Thus, SSI
is expected to be more prevalent in patients with
diabetes. The current study indicated a significant
association between diabetes mellitus and SSI. These
trends have been reported previously [19,20].
Chemotherapy and other immunosuppressive med-
ications affect the function of the immune system and
as a result the SSI rate, as expected, was higher [8].
Having a malignant disease is associated with higher
SSI rates [3]. However, our results did not fully support
this assumption: the risk for SSI was 1.56-fold higher
in patients previously diagnosed with cancer compared
with those never diagnosed with a malignant disease,
but this difference was not statistically significant
(p  0.064). A possible explanation is the relatively
small size of our cohort. Another plausible explanation
is that after completing the treatment cancer survivors
may no longer be at a higher risk for an SSI. We have
no data on the time elapsed since the cancer diagnosis,
and cannot rule out this explanation.
Other factors found in previous studies [1,3,8,11],
such as gender, malnutrition, chronic obstructive
pulmonary disease, and antimicrobial prophylaxis
had no significant associations with SSI incidence in
our cohort.
The majority of surgeries were classified as a
clean wound surgery, where the incidence of SSI is
low. This may partially explain the low effect of anti-
microbial prophylaxis in the present study.
Surgeries that lasted  120 min were significantly
associated with a higher SSI risk. Previous reports
score is to describe the preoperative condition of the
patient and to facilitate the statistical tabulation of
data. According to many investigators the ASA score
is a subjective variable for analysis, and can be used
as a proxy variable for a preoperative assessment of
the overall physical status of the patients [22,23].
The impact of drains is more clear-cut. Drains
placed in incisions may cause more infections than
they prevent. Sealing of the wound by epithelializa-
tion is prevented and the drain becomes a conduit
by holding open an entry into the wound for poten-
tial invasion by pathogens that colonize the skin.
Considering that drains pose this risk and accom-
plish less than expected their use should be minimal
and they should be removed as soon as possible [6].
Drain insertion in the present study was, as expected,
significantly associated with risk for SSI, in accor-
dance with previous reports [18].
The multivariate analysis demonstrated that
patients undergoing procedures classified as dirty
had an 8.84-fold higher risk of developing SSI com-
pared with those undergoing clean surgeries. Simi-
larly, previous reports found 7.40- and 9.91-fold risk
for SSI occurrence in potentially dirty surgeries [22].
Since most laparotomies are classified as contami-
nated or as dirty, it is not surprising that they are
associated with an increased risk for SSI. Open
cholecystectomy can range from clean to dirty sur-
gery depending on the presence or absence of a
related infection, such as cholecystitis, cholangitis, or
even biliary abscesses.
 6 A. Emil et al.
The majority of infections (90%) appear after
hospital discharge, 9–21 days post surgery [24]. In
the present study over 80% of the SSIs developed
after discharge, emphasizing the importance and
necessity of surveillance after discharge to avoid
underestimates of the rates of infection and biases
related to known risk factors.
The major benefit of the present study is docu-
mentation of SSI rates to serve as baseline data in
suspected local outbreaks in the future. Implementing
surveillance after discharge assures a high level of
completeness and validity of the recorded rates of SSI,
thus possibly avoiding underestimation, an obstacle
that many researchers have encountered [25,26].
The present study had some limitations. The
study population included 302 patients – a small
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15
sample size, as reflected by the very wide 95% CIs
in the multivariate analysis. Caution should thus be
observed in interpreting the results of the current
study. Furthermore, a high proportion of the study
participants (21%) reported a history of malignant
diseases. They are thus not representative of the gen-
eral population with regard to immune status.
For personal use only.
Conclusions
Surgical site infection is a common complication
affecting about one of every five patients undergoing
certain types of abdominal surgery.
Recommendations based on the current results
may be to taper or discontinue immunosuppressive
medications in non-urgent surgery. Minimally inva-
sive laparoscopic surgery reduces the rate of SSI, and
should be preferred to open cholecystectomy, when
possible.
The three most significant risk factors for SSI
(receiving immunosuppressant medications, open
cholecystectomy, and a dirty wound classification),
should be considered in every intervention plan
aimed at reducing the rates of SSI.
In addition, a periodic surveillance of SSIs with
a large volume sample throughout all surgery wards
in Israel is suggested, so as to expand our database
concerning SSI rates and related risk factors.­­­
Acknowledgments
This manuscript is based on work done as part of the
MPH thesis and studies of Emil Aga in the School of
Public Health, University of Haifa, Israel, supervised
by Dr Keinan-Boker. The authors would like to thank
the microbiology laboratory staff for their contribution
to the data collection, the nursing staff in the general
surgery ‘A’ ward for assisting with the identification of
the study cohort and the follow-up, and Ms Yakir Orly
for help with the statistical analyses.
Declaration of interest:  There was no financial
support for the study. All co-authors, except for
Dr Keinan-Boker were working at the Western
Galilee Medical Center during the study period. The
authors report no conflicts of interest.
References
[1] Owens CD, Stoessel K. Surgical site infections: epidemiology,
microbiology and prevention. J Hosp Infect 2008;
70(Suppl 2):3–10.
[2] Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ.
The impact of surgical-site infections in the 1990s: attributable
mortality, excess length of hospitalization, and extra costs.
Infect Control Hosp Epidemiol 1999;20:725–30.
[3] Meakins JL, Masterson BJ. Prevention of postoperative infec-
tion. In: WW Souba, editor. ACS surgery: principles and
practice. American College of Surgeons, Inc.; 2005.
[4] Gyanes RP. Surveillance of surgical site infections: the world
coming together? Infect Control Hosp Epidemiol 2000;21:
309–10.
[5] Vilar-Compte D, Roland K, Sandoval S, Corominas R,
De La Rosa M, Gordillo P. Surgical site infection in ambula-
tory surgery: a 5-year experience. Am J Infect Control
2001;29:99–103.
[6] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR;
Guideline for prevention of surgical site infection, 1999.
Hospital Infection Control Practice Advisory Committee.
Infect Control Hosp Epidemiol 1999;20:247–78.
[7] Dominioni L, Imperatori A, Rotolo N, Rovera F. Risk factors
for surgical infections. Surg Infect 2006;7:S9–S12.
[8] Horan TC, Gyanes RP, Martone WJ, Jarvis WR, Emori TG.
CDC definitions of nosocomial surgical site infections:
a modification of CDC definition of surgical wound infec-
tions. Infect Control Hosp Epidemiol 1992;13:606–8.
[9] Malone DL, Genuit T, Tracy JK, Gannon C, Napolitano LM.
Surgical site infections: re-analysis of risk factors. J Surg Res
2002;103:89–95.
[10] Vilar-Compte D, Roland K, Sandoval S, de la Rosa M,
Gordillo P, Volkow P. Surgical site infections at the National
Cancer Institute in Mexico: a case-control study. Am J Infect
Control 2000;28:14–20.
[11] Geubbels EL, Mintjes-de Groot AJ, van den Berg JM,
de Boer AS. An operating surveillance system of surgical-site
infections in The Netherlands: results of PREIEZ national
surveillance network. Infect Control Hosp Epidemiol
2000;21:311–18.
[12] Culver DH, Horan TC, Gaynes, Martone WJ, Jarvis WR,
Emori TG, et  al. Surgical wound infection rates by wound
class, operative procedure, and patient risk index. National
Nosocomial Infections Surveillance System. Am J Med
1991;91(3B):152S–157S.
[13] Hernandez K, Ramos E, Seas C, Henostroza G, Gotuzzo E.
Incidence of and risk factors for surgical site infections in a
Peruvian Hospital. Infect Control Hosp Epidemiol 2005;26:
473–7.
[14] Auerbach AD. Prevention of surgical site infection. In: Making
health care safer: a critical analysis of patient safety practices.
Agency for Healthcare Research and Quality; 2001
pp 221–44.
[15] Watters JM, McClaran JC, Mansonlting M. Surgery in the
elderly. Can J Surg 2002;45:104–8.
[16] Kaya E, Yetim I, Dervisoglu A, Sunbul M, Bek Y. Risk factors
for and effect of one-year surveillance program on surgical site
infection at a university hospital in Turkey. Surg Infect 2006;7:
519–26.

[17] Kaye KS, Sloane R, Sexton DJ, Schmader KA. Risk factors
for surgical site infections in older people. J Am Geriatr Soc
2006;54:391–6.
[18] Barie PS. Surgical site infections: epidemiology and preven-
tion. Surg Infect (Larchmt) 2002;3(Suppl 1):S9–21.
[19] Fiorio M, Marvaso FM, Vigano F, Marchetti F. Incidence of
surgical site infections in general surgery in Italy. Infection
2006;34:310–14.
[20] Cheadle WG. Risk factors for surgical site infection. Surg
Infect 2006;7:7–11.
[21] Leong G, Wilson J, Charlet A. Duration of operation as a risk
factor for surgical site infection: comparison of England and
US data. J Hosp Infect 2006;63:255–62.
[22] DeOliveira AC, Ciosak SI, Ferraz EM, Grinbaum RS. Surgi-
cal site infection in patients submitted to digestive surgery:
Infect Dis Downloaded from informahealthcare.com by Nyu Medical Center on 06/29/15
For personal use only.
Surgical site infections after abdominal surgery  7
risk prediction and the NNIS risk index. Am J Infect Control
2006;34:201–7.
[23] Clements ACA, Tong ENC, Morton AP, Whitby M. Risk
stratification for surgical site infections in Australia: evalua-
tion of the US National Nosocomial Infection Surveillance
risk index. J Hosp Infect 2007;66:148–55.
[24] Weigelt JA, Dryer D, Haley RW. The necessity and efficiency
of wound surveillance after discharge. Arch Surg 1992;127:
77–81; discussion 81–2.
[25] Sands K, Vineyard G, Platt R. Surgical site infections occur-
ring after hospital discharge. J Infect Dis 1996;173:963–70.
[26] Weiss CA 3rd, Statez CL, Dahms RA, Remucal MJ,
Dunn DL, Beilman GJ. Six years of surgical wound infection
surveillance at a tertiary care center. Arch Surg 1999;134:
1041–8.