Surgical Site Infection:
The Host Factor 1.9
DONALD E. FRY, MD; ROSEMARY V. FRY, RN, BSN, CNOR
I
t is estimated that in 2006 more than
30 million surgical procedures were
performed in the United States.1 Ac-
cording to the most recent National
Nosocomial Infections Surveillance
(NNIS) data, infection will have oc-
curred at the surgical site in 2.6% of
those surgical procedures.2 It is likely
that these statistics are underestimated,
however, because surgical site infection
(SSI) surveillance techniques are not ca-
pable of capturing all infections that
occur, particularly because the majority
of SSIs are not identified until after the
patient has been discharged.
An SSI is an unexpected event that
complicates a patient’s postoperative
course and adversely affects patient
outcomes. An SSI causes the patient
pain, misery, and possible deformity.
Furthermore, an SSI may require the
patient to undergo additional surgical
procedures or could result in the
patient’s death.
Surgical site infections are recog-
nized by the public and lay media as a
major medical problem because articles
and television exposés about medica-
tion errors, multidrug-resistant Staphy-
lococcus aureus (S aureus) infections in
hospitalized patients, wrong site
surgery, and SSIs frequently are pres-
ent in the public media. Public and
government agencies, such as the
indicates that continuing education contact
hours are available for this activity. Earn the con-
tact hours by reading this article and taking the
examination on pages 811–812 and then com-
pleting the answer sheet and learner evaluation
on pages 813–814.
You also may access this article online at
http://www.aornjournal.org.
© AORN, Inc, 2007
Centers for Disease Control and Pre-
vention and the Centers for Medicare
& Medicaid Services have made
decreasing the rate of SSIs a goal for
improvement.3,4 Pay-for-performance
initiatives for surgeons use SSI rates as
a performance measure,5 and public
reports of surgical outcomes in hospi-
tals place rates of SSIs at the top of the
list of areas for improvement.6
The National Surgical Infection
Prevention (SIP) Project established
reduction of potential SSIs by 40% to
60% as its objective,7 primarily focusing
on preventive antibiotic use in surgical
patients.8 The SIP now has transitioned
into the Surgical Care Improvement
Project (SCIP), which has a goal of
reducing the incidence of surgical
complications 25% nationally by the
year 2010; SSIs still are a major focus of
ABSTRACT
MORE THAN 30 MILLION surgical procedures are
performed annually in the United States, and sur-
gical site infections (SSIs) remain a major postop-
erative complication.
ALTHOUGH BACTERIA contaminate all surgical
wounds, not all wounds become infected. In most
cases, the host response eradicates the microbes.
The patient’s (ie, host’s) responsiveness, therefore,
is an important variable in the equation of factors
that influence the rate of infection.
OPTIMIZING THE PATIENT’S PHYSIOLOGICAL
condition can help prevent SSIs. Initiatives that
show promise in reducing SSI rates include use of
supplemental oxygen, maintenance of core body
temperature, and rigorous management of blood
sugar. Perioperative nurses play an important role
as the patient’s infection control advocate. AORN J
86 (November 2007) 801-810. © AORN, Inc, 2007.
NOVEMBER 2007, VOL 86, NO 5 • AORN JOURNAL • 801
NOVEMBER 2007, VOL 86, NO 5
TABLE 1
Surgical Care Improvement
Project (SCIP) Infection
Control Measures1
SCIP Inf #1—Prophylactic antibiotics should
be received within one hour before the surgical
incision.
SCIP Inf #2—Prophylactic antibiotic selection
should be appropriate and specific for surgical
patients.
SCIP Inf #3—Prophylactic antibiotics should be
discontinued within 24 hours after surgery end
time (48 hours for cardiac patients).
SCIP Inf #4—Cardiac surgery patients should
have a controlled 6 AM postoperative serum
glucose (ie, less than or equal to 200 mg/dL).
SCIP Inf #5—Postoperative wound infection
should be diagnosed during the index hospi-
talization.
SCIP Inf #6—Surgery patients should undergo
appropriate hair removal, when necessary.
SCIP Inf #7—Colorectal surgery patients
should have immediate postoperative
normothermia.
1. Surgical Care Improvement Project: infections.
MedQic. http://www.medqic.org/dcs/ContentServer
?cid=1089815967030&pagename=Medqic%2FCon
tent%2FParentShellTemplate&parentName=Topic
&c=MQParents. Accessed September 10, 2007.
interest.9 Table 1 lists the infection measures
that the SCIP has identified.
The federal government also has become
involved in the issue of SSIs.10 The Deficit
Reduction Act of 2005 requires that specific
national hospital inpatient performance meas-
ures be reported for Medicare patients, and
hospitals face economic penalties for noncom-
pliance.10 For surgery, the use of antibiotics for
the prevention of SSIs is a top priority. The
Deficit Reduction Act also instructs the Secre-
tary of Health and Human Services to begin
phasing out payment increases associated with
complications of care. Economic sanctions are
802 • AORN JOURNAL
Fry — Fry
expected to improve clinical outcomes of care
and reduce the frequency of SSIs.10
Discussion of SSIs has focused on the failure
of physicians, nurses, and hospitals to perform
in a fashion that should yield ideal results. The
reality is that SSIs are the consequence of a
multitude of variables. This article discusses
the causative factors of SSIs and identifies the
clinical variables of the patient (ie, host factor)
that affect SSI rates. Although specific elements
of host responsiveness will not be discussed in
detail, host responsiveness in the context of
this discussion will refer to the general pres-
ence of inflammation, phagocytic responses,
and the specific immunologic responses (eg,
antibody production) that enable humans to
avoid infection from the environment. New
directions in SSI prevention are presented and
methods describing how perioperative nurses
must be active participants in these processes
are discussed.
PREDICTORS OF SSIS
Intact skin is the patient’s first line of defense
against bacterial invasion. A surgical incision is
an intentional breech of this defense mechanism,
after which the surgical wound can be contami-
nated by bacteria from multiple sources. Conta-
mination may come from normal colonization of
the patient’s skin or may enter the wound via
“fall out” from dispersed bacteria in the air of
the OR,11 which is the rationale for using special-
ized air handling and laminar flow systems to
reduce potential contamination.
Surgical entry into areas with heavy colo-
nization (eg, the colon, the female genital tract)
may result in wound contamination from
endogenous microorganisms that reside within
the patient. Infection virtually never occurs at
the surgical site from bloodborne bacteria from
remote sources.12 Typically, bacteria responsi-
ble for SSIs are introduced into the wound at
the time of the surgical procedure; however,
infection may not be evident for many days or
even weeks after the surgical procedure.
The multitude of different sources of bacteria
that contaminate the wound can lead to a few
fundamental conclusions. First, all surgical
wounds are contaminated by bacteria, but only
a small minority of surgical wounds actually
Fry — Fry NOVEMBER 2007, VOL 86, NO 5

air in the OR skin endotoxins exotoxins

Virulence of
Inoculum of bacteria
bacteria

antibiotic
surgical team
visceral
Probability of resistance
(eg, skill levels,
surgical colonization Infection
technique)

dead tissue dead space

Microenvironment
of the surgical site
foreign
hematoma
bodies

Figure 1 • Surgical site infections occur because of multiple factors: bacterial inoculum, which may come from a variety of sources;
virulence of the bacteria that may contaminate the wound, which varies from patient to patient; and the conditions of the micro-
environment of the wound, which is affected by hemostasis, electrosurgery, silk sutures, and dead space in the wound. All of these
factors may result in infection in a patient, but the absence of these variables may lead to an uneventful recovery.

become infected.13 A cultured biopsy of the
surgical wound at the end of the procedure will
document that bacteria are present. Second,
different surgical procedures have different
numbers of bacteria that may contaminate the
wound; increased numbers of bacteria within
the wound will result in increased infection
rates. Third, the same surgical procedure
performed by the same surgeon with the same
degree of contamination in different patient
populations can result in different rates of infec-
tion. The patient’s (ie, host’s) responsiveness,
therefore, is an important variable in the equa-
tion of factors that influence the rate of infec-
tion. The three major variables associated with
SSIs are illustrated in Figure 1.
THE INOCULUM. The bacterial inoculum (ie, the
quantity of bacteria that contaminate the
wound during the surgical procedure) is the
variable most used and of greatest concern in
the prediction of SSIs. Clean surgical proce-
dures (eg, thyroidectomy, inguinal herniorrha-
phy) have low SSI rates because the patient’s
skin is the likely source of contamination.
Staphylococcus from the skin is the major
pathogen, but with appropriate antiseptic
preparation of the surgical site, infection in
these clean procedures should be low (ie, 1%).14
During clean-contaminated surgical proce-
dures, a normally colonized visceral structure
is surgically entered under controlled circum-
stances. Colonic resection and hysterectomy
are examples in which the human colon or the
female genital tract, respectively, are entered,
and significant contamination of the surgical
site may occur as a result. The microbiology of
these clean-contaminated procedures reflects
the aerobic and anaerobic colonists of the
anatomic structure.
THE VIRULENCE FACTORS. A second important vari-
able is the virulence of the bacterial contami-
nant. Different bacteria have a varied propensi-
ties to cause infection. Staphylococcus aureus has
more virulent factors (eg, coagulase) than does
Staphylococcus epidermidis (S epidermidis). So
although S epidermidis may be a more common

AORN JOURNAL • 803

NOVEMBER 2007, VOL 86, NO 5 Fry — Fry

contaminant of the surgical wound, it is infre- rates at very low levels. When host responsive-
quently the pathogen of infection. Resistance to ness is compromised, SSIs occur more frequent-
antibiotics, another virulence factor, is becoming ly. Host responsiveness is affected by both
more problematic in SSIs. Methicillin-resistant genetic and acquired factors. Genetic variability
S aureus (MRSA) has become a more common dictates a baseline of efficiency and effective-
pathogen in SSIs because of its resistance to ness in response to potential pathogens from
common antibiotics used for prophylaxis. The the environment. This genetic variation means
newly recognized community-associated MRSA that some people are genetically less prone to
has both antibiotic resistance and an equally infection than others. Measurement of geneti-
potent exotoxin (ie, Panton-Valentine leuko- cally programmed host responses has been
cidin) that gives it a particularly important role elusive, and it remains unclear what quantita-
as an emerging pathogen of the surgical site.15 tive effect this actually has on SSIs and other
THE MICROENVIRONMENT OF THE WOUND. A third vari- infection rates in surgical patients.
able that permits infection is the microenviron- Acquired impairment of host responsive-
ment of the surgical wound itself. Hemoglobin ness appears to be a more commonly studied
from red cells and hematoma (ie, clot) within issue in regard to SSIs. Figure 2 details many
the wound is a rich source of iron, which pro- of the variables that adversely affect the host.
motes rapid bacterial replication and results in Some of the variables are naturally occurring
enhanced virulence. Devitalized tissue from events (eg, aging), others are a result of acute
surgical trauma and necrotic tissue from electro- physiologic events (eg, hypoglycemia), while
surgery become havens for bacterial prolifera- still others actually relate to treatments admin-
tion. Foreign bodies such as silk sutures increase istered to patients (eg, transfusion, corticos-
the probability that a given contaminant will teroid treatments).
cause infection. Plasma and body fluids accu- Recent studies have focused on the role of
mulate in dead space within the wound, and these clinical variables on SSI rates. Dunne et
the bacterial contaminants within this accumu- al16 studied nearly 500 patients undergoing
lated fluid increase the likelihood of infection. abdominal wall hernia repair. The researchers
Thus, were it not for an effective host defense found that SSIs occurred in 4.3% of patients.
system, the interactive and
collective effects of the
• inoculum, Host
• virulence factors, and Defense System
• microenvironment of the
wound
would result in virtually all Acute physiologic Chronic conditions
surgical sites being infected. As events or changes or variables
the host response is negatively • Hyperglycemia • Age
affected by systemic factors, • Hypothermia • Alcoholism
these pro-infection variables
• Hypovolemia • Chronic lung disease
• Hypoxia • Chronic steroid use
will have an increased effect on • Shock • Diabetes
infection rates. • Transfusion • Hypoalbuminemia/
malnutrition
THE HOST • Obesity
The innate host response is
an important factor in the Figure 2 • The host defense system is a complex combination of innate and adaptive
equation that produces an SSI. responses that prevent infection from occurring with every surgical procedure that
Within limits, the host respon- the host experiences. Many acute physiologic changes can be managed during the
siveness can eradicate bacterial preoperative, intraoperative, and postoperative periods so that infection can be
contaminants in the surgical prevented. Chronic medical conditions also affect the host’s defenses and increase
wound and maintain infection the likelihood that the patient will incur a surgical infection.

804 • AORN JOURNAL

Fry — Fry
Risk factors associated with increased infection
rates were
• surgical time longer than four hours,
• chronic pulmonary disease, and
• decreased preoperative serum albumin
concentration.
It is interesting to note that the researchers found
that increasing age was not an associated factor.
Imperatori et al17 studied nearly 1,000 patients
undergoing open lung resection. Infection at the
surgical site, of the lung itself, or both occurred
in 14% of patients. The researches identified the
following risk factors:
• surgical procedures lasting more than three
hours;
• patient age greater than 70 years;
• serum albumin less than 3.5 g/dL; and
• existence of medical comorbidities (eg,
diabetes, chronic obstructive pulmonary
disease).
Schwartz et al18 studied more than 2,000
patients undergoing laryngectomy. Researchers
observed an overall SSI rate of 10%. Identified
risk factors included
• prolonged surgical time (ie, greater than 10
hours);
• prior radiation of the surgical site;
• diabetes;
• hypoalbuminemia;
• anemia; and
• thrombocytosis.
Cardiac surgical procedures have been of
particular interest in regard to the host factor in
SSIs. Harrington et al19 studied more than 4,000
patients undergoing coronary artery bypass
grafting and found an overall SSI rate of 7.8%.
Increasing age, diabetes, and obesity were
significant variables associated with infection.
Banbury et al20 studied more than 15,000
cardiovascular surgery patients at the Cleve-
land Clinic, Ohio. They reported infection
rates by severity criteria:
• superficial infection occurred in 2.3% of
patients,
• deep infection in 1.4%, and
• septic/bacteremic infection in 2.2%.
They identified blood transfusions, obesity,
chronic obstructive pulmonary disease
(COPD), and diabetes as risk factors.
De Oliverra et al21 studied more than 600
NOVEMBER 2007, VOL 86, NO 5
Different surgical procedures studied by
various investigators among varied
populations of patients resulted in
different host variables being
implicated in infection. Acquired host
variables affect host responsiveness, but
no consensus exists about which
variables have the greatest influence.
patients undergoing surgical procedures of the
digestive tract. The researchers found that 22%
of the patients acquired an infection. Using
logistic regression analysis, the researchers deter-
mined that obesity and long procedures had the
greatest odds ratios for predicting infection.
Kaye et al22 evaluated more than 500 surgical
procedures in patients older than 65 years. The
researchers determined that obesity and COPD
were significant variables. Undergoing a clean-
contaminated or contaminated procedure also
was significant. The researchers noted that the
socioeconomic variable of not having private
insurance also was associated with SSIs.
Different surgical procedures studied by vari-
ous investigators among varied populations of
patients resulted in different host variables
being implicated in SSI. The uncertainty of vari-
ables may result from the fact that no standard
type of variable has been examined in each of
the studies. The results of these studies indicate
that acquired host variables affect host respon-
siveness, but no consensus exists about which
variables have the greatest influence.
AUGMENTATION OF THE HOST
Prevention of SSIs has largely focused on
methods to reduce variable bacteria in the wound
at the completion of the procedure. Antiseptic
AORN JOURNAL • 805
NOVEMBER 2007, VOL 86, NO 5
preparation of the surgical site and use of preven-
tive systemic antibiotics are examples of strategies
commonly employed for this purpose. The ques-
tion remains whether other strategies (eg, nutri-
tional management to avoid hypoalbuminemia,
avoiding hypothermia, maintaining blood
glucose levels within normal limits) can be
applied to improve host responsiveness in the
surgical patient.
Evidence indicating that enhanced
oxygenation decreases
surgical site infections (SSIs) is not
conclusive; additional studies are needed
to validate the use of supplemental
oxygen to achieve SSI reduction.
HYPOALBUMINEMIA. Hypoalbuminemia is a
surrogate marker for protein malnutrition and
can indicate that nutritional management
should be implemented before the surgical
procedure, if practical.23 Reduced use of trans-
fusions and greater use of autologous blood
donation before selected procedures would
seem to have some utility.24 Even immune
modulation has been explored with medica-
tion administration to enhance the host’s
immune system, especially in emergency
surgical situations,25,26 but none of these treat-
ment options have been accepted as routine
clinical practice.
TISSUE OXYGENATION. In recent years, renewed
attention has focused on optimizing the
patient’s physiology to enhance the host’s
resistance to SSIs. Tissue oxygen availability
has experimentally been shown to enhance
the host’s resistance to SSIs and may do so by
improving the bacteriocidal function of
806 • AORN JOURNAL
Fry — Fry
human phagocytic cells.27 Several studies have
investigated providing supplemental oxygen
to increase intraoperative and early postopera-
tive inspired oxygen concentration in an effort
to improve SSI rates. Greif et al28 and Belda et
al29 demonstrated reduced SSIs in elective
colorectal surgery by using a fraction of
inspired oxygen (ie, FiO2) of 0.8 compared to
0.3. Pryor et al,30 however, studied major intra-
abdominal surgery with an FiO2 of 0.8 com-
pared to 0.35 and demonstrated an increased
infection rate with oxygen supplementation.
Although a strong intellectual case can be made
for use of supplemental oxygenation, evidence
indicating that it decreases SSIs is not conclu-
sive at this point, and additional studies are
needed to validate the use of supplemental
oxygen to achieve a reduction in SSIs.
HYPOTHERMIA. Passive hypothermia is a known
problem for patients undergoing surgical proce-
dures of the major body cavities. Core body
temperature plays a role in the vigor of phago-
cytic cell function. Kurz et al31 studied whether
maintenance of core body temperature at or
above 36.5° C (97.7° F) would improve SSI rates
in patients undergoing elective colon surgery
compared with patients whose core tempera-
tures were allowed to drop as low as 34.5° C
(94.1° F). Maintaining higher temperatures
reduced the incidence of SSIs from 19% to 6%.
HYPERGLYCEMIA AND HYPOGLYCEMIA. Elevated blood
sugar concentration impaired the function of
phagocytic cells in experimental studies.32
Furnary et al33 demonstrated significant reduc-
tion in sternal SSI rates in diabetic patients
undergoing open heart surgery by maintaining
intraoperative blood sugar at less than 200
mg/dL. Zerr et al34 showed that infection rates
in cardiac surgery proportionally declined as
blood sugar concentrations were reduced from
300 mg/dL to 100 mg/dL. Van den Berghe et
al35 identified reduction in septic deaths among
postoperative patients when blood sugar was
maintained between 80 mg/dL and 110 mg/dL.
Hypoglycemia also is thought to impair
phagocytic cell function. Intraoperative and
postoperative blood sugar control remains a
logistical problem. Furthermore, the ideal blood
sugar level remains undefined. It generally is
agreed that maintaining euglycemia (ie, normal
Fry — Fry NOVEMBER 2007, VOL 86, NO 5

TABLE 2
Factors to Consider When Preparing the
Patient’s Skin for a Surgical Procedure
When preparing the patient’s skin for a surgical procedure, special considerations should include
• preparing1-4areas of high microbial counts within the prepared areas last (eg, umbilicus, pubis, open
wounds);
• isolating colostomy site(s) from the prepared area, covering the site(s) with an antiseptic-soaked
sponge, and preparing the colostomy site(s) last;2-3
• using normal saline to prepare burned, denuded, or traumatized skin;2
• avoiding using chlorhexidine gluconate and/or alcohol or alcohol-based products on mucous
membranes;5,6
• using gentle preparation techniques when preparing skin of patients with certain medical conditions
(eg, diabetes, skin ulcerations);6(p79)
• allowing sufficient contact time of antiseptic agents with the skin before applying sterile drapes to achieve
maximum effectiveness of the agent;7-9
• allowing sufficient time for complete evaporation of any flammable antiseptic agent (eg, alcohol,
alcohol-based preparations) to reduce the possibility of fire;6(p79),9(p257) and
• preventing the antiseptic agent from pooling beneath patients, pneumatic tourniquet cuffs, electrodes,
or electrosurgical unit dispersive pads to reduce the risk of chemical burns.

1. Earl A. Operating room. In: APIC Infection Control and Applied Epidemiology: Principles and Practice.
St Louis, MO: Mosby; 1996:95-101.
2. Fortunato NH. Berry & Kohn’s Operating Room Technique. 9th ed. St Louis, MO: Mosby; 2000:507.
3. Fairchild SS. Patient care management. In: Fairchild SS, ed. Perioperative Nursing: Principles and Practice.
2nd ed. Boston, MA: Little, Brown and Co; 1996:333.
4. Fogg D. Infection control. In: Meeker MH, Rothrock JC, eds. Alexander’s Care of the Patient in Surgery. 11th
ed. St Louis, MO: Mosby; 1999:145.
5. Briggs M. Principles of closed surgical wound care: a review of the factors before, during and after surgical proce-
dures that may predispose patients to post-operative wound infection. J Wound Care. 1997;6(6):290.
6. Mews PA. Establishing and maintaining a sterile field. In: Phippen ML, Wells MP, eds. Patient Care During
Operative and Invasive Procedures. Philadelphia, PA: WB Saunders Co; 2000:79-80.
7. Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Contr. 1988;16(6):259.
8. Rutala W. APIC guidelines for infection control practice: APIC guideline for selection and use of disinfectants.
Am J Infect Contr. 1996;24(4):330, 334.
9. Mangram A J, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection,
1999. Infect Cont Hosp Epidemiol. 1999;20(4):250-278.

Adapted with permission from Recommended practices for skin preparation of patients. In: Standards, Recom-
mended Practices, and Guidelines. Denver, CO: AORN, Inc; 2007:654-655.

blood glucose concentration) for the patient is
desirable.32-35 Future developments in real-
time, on-line measurement of blood glucose
will allow this conundrum to be resolved.
THE EVER-CHANGING ROLE OF PERIOPERATIVE NURSES
Perioperative nursing activities in caring
for surgical patients can increase the host’s
resistance to SSIs. Nurses in the preoperative
holding area, OR, and postanesthesia care unit
must deal with important infection control
responsibilities. In addition to traditional
roles, perioperative nurses often play the role
of infection control officer.
In preoperative holding, nurses are respon-
sible for coordinating preoperative antibiotic
administration. Antibiotics should be adminis-
tered between 30 minutes and one hour before
incision depending on the type of prophylac-
tic medication used.36 This may occur in the
preoperative holding area, or the medications
may be transported with the patient and ad-
ministered enroute to the OR in an effort to
avoid the problem of the antibiotics being

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NOVEMBER 2007, VOL 86, NO 5
initiated in preoperative holding only to have
an unanticipated delay in the procedure result
in the administration having been premature.
In the preoperative holding area and the OR,
appropriate methods for hair removal and prepa-
ration of the surgical site commonly are the nurs-
es’ responsibility.37 Hair should be left at the surgi-
cal site whenever possible. If it is determined that
hair should be removed, only personnel skilled in
hair removal techniques should perform the
removal. The hair should be removed as close to
the time of surgery as possible, except when a
depilatory is used, and should be performed in a
manner that preserves skin integrity. The hair
removal process should be performed in an area
outside of the room where the procedure will be
performed. If possible, an electric or battery-
powered clipper with a disposable or reusable
head that can be disinfected between uses should
be used. Razors can disrupt skin integrity so hair
removal with a razor is not recommended.
When indicated, the surgical site and
surrounding area should be prepared with an
antiseptic solution.37 Performing the surgical
skin preparation can become a casual routine,
but it must be performed with thoroughness
to reduce potential pathogens that colonize
the patient’s skin. The circulating nurse
should uniformly apply the prep solution
using sterile supplies in a contiguous fashion
circumferentially from the incision site to the
periphery. The sponge/applicator should be
discarded after the periphery has been
reached. Table 2 provides additional skin
preparation techniques that should be em-
ployed to prepare the surgical site in a manner
that preserves skin integrity and prevents
injury to the patient’s skin.
The surgical “time out” has become a valu-
able method to verify the patient’s identity;
correct surgical site and laterality, if applicable;
and availability of needed supplies, equipment,
and implants. Some facilities also are using the
time out to verify that preoperative antibiotics
were administered at the appropriate time.
Those facilities may require in their time-out
policy that the perioperative nurse initiate an
additional time out during long procedures
when redosing of antibiotics is required.
As technology that affects a patient’s
808 • AORN JOURNAL
Fry — Fry
susceptibility to SSIs evolves, such as that used
to maintain the patient’s core body temperature,
perioperative nurses will continue to be in-
volved in the maintenance and operation of that
equipment. Continuous glucose monitoring
technology also is likely to change dramatically
in coming years, and perioperative nurses will
need to remain informed regarding the use of
new equipment. Furthermore, postanesthesia
care unit nurses will continue to be responsible
for early postoperative administration of oxy-
gen, control of core body temperature, and
glycemic management.
It is likely that newer and more intense efforts
to improve outcomes from SSIs will continue. The
SCIP will develop both process and outcome
measures that will expand the total spectrum of
preventive methodologies, the responsibility for
which may fall to perioperative nurses.38 It also is
likely that these continued efforts will have
preoperative, intraoperative, and postoperative
nursing activities as the primary focus of atten-
tion, because preparation of the patient and
management of intraoperative contamination has
the greatest likelihood of reducing SSI rates.
Understanding the evidence on which these prac-
tices are based will remain important for periop-
erative nurses of the future so that these newer
techniques can be applied in efficient and effec-
tive ways.
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14. Cruse PJ, Foord R. The epidemiology of wound in-
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producing Staphylococcus aureus in primary
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1999;29(5):1128-1132.
16. Dunne JR, Malone DL, Tracy JK, Napolitano
LM. Abdominal wall hernias: risk factors for infec-
tion and resource utilization. J Surg Res. 2003;111
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17. Imperatori A, Rovera F, Rotolo N, Nardecchia E,
Conti V, Dominioni L. Prospective study of infec-
tion risk factors in 988 lung resections. Surg Infect
(Larchmt). 2006;7(Suppl 2):S57-S60.
18. Schwartz SR, Yueh B, Maynard C, Daley J,
Henderson W, Khuri SF. Predictors of wound
complications after laryngectomy: a study of
over 2,000 patients. Otolaryngol Head Neck Surg.
2004;131(1):61-68.
19. Harrington G, Russo P, Spelman D, et al. Surgical-
site infection rates and risk factor analysis in coronary
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20. Banbury MK, Brizzio ME, Rajeswaran J, Lytle
BW, Blackstone EH. Transfusion increases the risk
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gery. J Am Coll Surg. 2006;202(1):131-138.
21. De Oliveira AC, Ciosak SI, Ferraz EM, Grinbaum
RS. Surgical site infection in patients submitted to di-
gestive surgery: risk prediction and the NNIS risk
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22. Kaye KS, Sloane R, Sexton DJ, Schmader KA.
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ple. J Am Geriatr Soc. 2006;54(3):391-396.
23. Khuri SF, Daley J, Henderson W, et al. The De-
partment of Veterans Affairs’ NSQIP: the first na-
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and peer-controlled program for the measurement
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24. Walz JM, Paterson CA, Seligwoski JM, Heard
SO. Surgical site infection following bowel surgery:
a retrospective analysis of 1,446 patients. Arch Surg.
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25. Meakins JL, Christou NV, Shizgal HM, MacLean
LD. Therapeutic approaches to anergy in surgical pa-
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27. Hopf HW, Hunt TK, West JM, et al. Wound tissue
oxygen tension predicts the risk of wound infection
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29. Belda FJ, Aguilera L, Garcia de la Asuncion J, et al.
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gical wound infection: a randomized controlled trial.
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30. Pryor KO, Fahey TJ 3rd, Lien CA, Goldstein
PA. Surgical site infection and the routine use of
perioperative hyperoxia in a general surgical popu-
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31. Kurz A, Sessler DI, Lenhardt R. Perioperative
normothermia to reduce the incidence of surgical-
wound infection and shorten hospitalization. Study
of Wound Infection and Temperature Group. N Engl
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32. Turina M, Fry DE, Polk HC Jr. Acute hyper-
glycemia and the innate immune system: clinical,
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33. Furnary AP, Gao G, Grunkemeier GL, et al.
Continuous insulin infusion reduces mortality in
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bypass grafting. J Thorac Cardiovasc Surg. 2003;125
(5):1007-1021.
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S, Kanhere V, Starr A. Glucose control lowers the
risk of wound infection in diabetics after open heart
operations. Ann Thorac Surg. 1997;63(2):356-361.
35. Van den Berghe G, Wouters P, Weekers F,
et al. Intensive insulin therapy in the critically ill
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AORN JOURNAL • 809
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36. AORN guidance statement: Preoperative pa-
tient care in the ambulatory surgery setting. In:
Standards, Recommended Practices, and Guidelines.
Denver, CO: AORN, Inc; 2007:319-324.
37. Recommended practices for skin preparation of
patients. In: Standards, Recommended Practices, and
Guidelines. Denver, CO: AORN, Inc; 2007:653-656.
38. Surgical Care Improvement Project. MedQIC.
http://medqic.org/dcs/ContentServer?cid=113734
6750659&pagename=Medqic%2FContent%2FParent
ShellTemplate&parentName=TopicCat&c=MQPar
ents. Accessed September 20, 2007.
RESOURCES
Fry DE. The economic costs of surgical site infec-
tion. Surg Infect. 2002;3(Suppl 1):S37-S43.
Recommended practices for Prevention of trans-
Serial Wound Debridement May Increase Healing Rates
S erial surgical debridement of chronic lower extrem-
ity wounds may increase the healing rates for
these wounds, according to an August 16, 2007, news
release from Advanced Biohealing, Inc, Philadelphia,
Pennsylvania. Researchers analyzed data from more
than 500 patients enrolled in two large clinical stud-
ies of wound healing and found that the median re-
duction in wound area was 54% higher for wounds
that were serially debrided within the first four weeks
of the treatment period compared with wounds that
were not debrided. In addition, venous leg ulcers that
Pelvic Health Disorders Affect One-Third of US Women
A t least one-third of the women in the United
States (ie, about 35 million) will be treated for a
pelvic health condition by the age of 60, according
to a June 19, 2007, news release from the National
Women’s Health Resource Center (NWHRC). A new re-
port from the NWHRC revealed information about
four pelvic health conditions: menorrhagia (ie, heavy
menstrual bleeding); uterine fibroids; stress urinary
incontinence (SUI); and pelvic organ prolapse (POP).
Researchers estimate that even more women
are affected by these disorders, but these women
often are misdiagnosed or underdiagnosed and re-
main untreated because they do not realize their
symptoms are abnormal or because they are too
embarrassed to talk to their physician about them.
Data indicate that 50% to 75% of SUI cases and
80% to 90% of POP cases likely are unreported. Yet
pelvic health conditions can seriously affect quality
of life, with symptoms ranging from sexual dys-
810 • AORN JOURNAL
Fry — Fry
missible infections in the perioperative practice set-
ting. In: Standards, Recommended Practices, and
Guidelines. Denver, CO: AORN, Inc; 2007:707-717.
Donald E. Fry, MD, is the executive vice pres-
ident of Michael Pine and Associates consult-
ing firm, Chicago, IL. Dr Fry has no declared af-
filiation that could be perceived as a potential con-
flict of interest in publishing this article.
Rosemary V. Fry, RN, BSN, CNOR, is a re-
tired OR nurse from Chicago, IL. Ms Fry has no
declared affiliation that could be perceived as a po-
tential conflict of interest in publishing this article.
were debrided at more than half of the patients’ study
visits in the first month had a better chance of reach-
ing 75% wound closure in four weeks and 90% to
100% wound closure in 12 weeks. Diabetic foot ulcers
that were debrided at every study visit for 12 weeks
also had a much greater chance of reaching total
wound closure than ulcers debrided less often.
Advanced Biohealing and leading researchers release data
from landmark wound care analysis [news release]. Philadel-
phia, PA: Advanced Biohealing, Inc; August 16, 2007.
function, discomfort, and abdominal pain to com-
plications with pregnancy and fertility, anemia, low
self-esteem, and depression.
By age 50, more than 70% of Caucasian women
and 80% of African-American women have developed
uterine fibroids. In 2005, a primary diagnosis of
uterine fibroids or menorrhagia accounted for 44% of
all hysterectomies performed (ie, about 600,000 per
year). This rate has remained constant for 25 years
despite the increased availability of minimally inva-
sive options. Researchers recommend that rigorous
studies be conducted to assess the viability and ef-
fectiveness of treating pelvic disorders with minimal-
ly invasive procedures, such as endometrial ablation
for heavy menstrual periods.
Baby Boomer women hardest hit by pelvic health condi-
tions, says new report [news release]. Washington, DC: The
National Women’s Health Resource Center; June 19, 2007.
 Examination 1.9

Surgical Site Infection: The Host Factor

PURPOSE/GOAL
To educate perioperative nurses about the host factor’s effect on surgical site infections (SSIs).

BEHAVIORAL OBJECTIVES
After reading and studying the article on SSIs and the host factor, nurses will be able to

1. discuss causes of SSIs,

2. identify clinical variables of the patient that affect SSI rates, and
3. describe care that optimizes the patient’s condition to help prevent SSIs.

QUESTIONS
1. A surgical wound may be contaminated
by bacteria from
1. normal colonization of the patient’s skin.
2. the air in the OR.
3. surgical entry into areas with heavy colo-
nization of endogenous microorganisms.
a. 1 and 2
b. 2 and 3
c. 1, 2, and 3
2. The major variables associated with SSIs are
1. inoculum of bacteria.
2. microenvironment of the surgical site.
3. virulence of bacteria.
a. 1 and 3
b. 2 and 3
c. 1, 2, and 3
3. Staphylococcus epidermidis is the most com-
mon surgical wound contaminant and
is therefore most often the pathogen of
infection.
a. true
b. false
4. The microenvironment of the surgical
wound permits infection because
1. devitalized and necrotic tissue become
havens for bacterial proliferation.
2. foreign bodies such as silk sutures in-
crease the probability that a contami-
nant will cause infection.
3. hemoglobin and hematoma in the
wound are a rich source of iron that
promote bacterial growth.
a. 1 and 3
b. 2 and 3
c. 1, 2, and 3
5. Although some people are genetically less
prone to infection than others, there is no
clear measurement of genetically pro-
grammed host responses.
a. true
b. false
6. Acute physiologic events or changes that
increase the risk of SSIs include
1. being obese.
2. having chronic lung disease.
3. experiencing hypovolemia.
4. suffering from shock.
5. undergoing a blood transfusion.
a. 2 and 3
b. 3, 4, and 5
c. 2, 3, 4, and 5
d. 1, 2, 3, 4, and 5
7. Strategies that can be employed to im-
prove host responsiveness in the surgical
patient include
1. avoiding hypoalbuminemia with

© AORN, Inc, 2007 NOVEMBER 2007, VOL 86, NO 5 • AORN JOURNAL • 811
NOVEMBER 2007, VOL 86, NO 5 Examination

proper nutritional management. 3. as close to the time of surgery as pos-

2. ensuring antiseptic preparation of the sible, except when a depilatory is used.
surgical site. 4. only by personnel skilled in hair removal
3. maintaining blood glucose levels within techniques.
normal limits. a. 1 and 2
4. preventing hypothermia. b. 3 and 4
a. 1 and 2 c. 1, 2, and 4
b. 3 and 4 d. 1, 2, 3, and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4 10. Some factors to consider when preparing
the patient’s skin for a surgical procedure
8. Preoperative antibiotics should be admin- include
istered between _____________ minutes 1. allowing sufficient time for complete
before the incision is made, depending on evaporation of any flammable antisep-
the type of prophylactic medication used. tic agent.
a. 20 and 40 2. allowing sufficient contact time of anti-
b. 30 and 60 septic agents with the patient’s skin be-
c. 40 and 80 fore applying sterile drapes.
d. 60 and 100 3. avoiding use of chlorhexidine gluconate
and alcohol or alcohol-based products on
9. Hair should be left at the surgical site mucous membranes.
whenever possible, but if it is determined 4. preparing areas of high microbial counts
that hair removal is necessary, it should within the prepared areas last.
be performed 5. preventing antiseptic agent pooling.
1. with a disposable razor rather than a a. 2 and 3
depilatory or electric razor. b. 1, 4, and 5
2. in the room where the procedure will be c. 2, 3, 4, and 5
performed. d. 1, 2, 3, 4, and 5

The behavioral objectives and exam-
ination for this program were prepared
by Rebecca Holm, RN, MSN, CNOR,
clinical editor, with consultation from
Susan Bakewell, RN, MS, BC, director,
Center for Perioperative Education.
This program meets criteria for CNOR and CRNFA recertification,
as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Center’s Commission on Accreditation.
AORN is provider-approved by the California Board of Registered
Nursing, Provider Number CEP 13019. Check with your state board
of nursing for acceptance of this activity for relicensure.

812 • AORN JOURNAL

 Answer Sheet 1.9
Event #07054
Surgical Site Infection: The Host Factor Session #8466

lease fill out the application and answer form

P on this page and the evaluation form on the back
of this page. Tear the page out of the Journal or make
photocopies and mail with appropriate fee to:

AORN Customer Service

c/o AORN Journal Continuing Education
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax with credit card information to
(303) 750-3212.
Additionally, please verify by signature that you
have reviewed the objectives and read the
article, or you will not receive credit.

Signature ______________________________________
1. Record your AORN member identification number in
the appropriate section below. (See your member
card.)
2. Completely darken the spaces that indicate your
answers to examination questions 1 through 10. Use
blue or black ink only.
3. Our accrediting body requires that we verify the time
you needed to complete this 1.9 continuing education
contact hour (114-minute) program. ______
4. Enclose fee if information is mailed.
AORN (ID) #____________________________________________
Name__________________________________________________
Address ________________________________________________
City ___________________________________________________ State __________ Zip __________
Phone number __________________________________________
RN license #____________________________________________ State __________
Fee enclosed ___________________________________________
or bill the credit card indicated ■ MC ■ Visa ■ American Express ■ Discover
Card # ___________________________________ Expiration date _____________________

Signature _________________________________________________ (for credit card authorization)

Fee: Members $9.50
Nonmembers $19
Program offered November 2007
The deadline for this program is November 30, 2010
A score of 70% correct on the examination is required for credit.
Participants receive feedback on incorrect answers.
Each applicant who successfully completes this program
will receive a certificate of completion.

© AORN, Inc, 2007 NOVEMBER 2007, VOL 86, NO 5 • AORN JOURNAL • 813
1.9 Learner Evaluation
Surgical Site Infection: The Host Factor

his evaluation is used to determine the

T extent to which this continuing education
program met your learning needs. Rate these
items on a scale of 1 to 5.

PURPOSE/GOAL
To educate perioperative nurses about the host
factor’s effect on surgical site infections (SSIs).

OBJECTIVES
To what extent were the following objectives of
this continuing education program achieved?
1. Discuss causes of SSIs.
2. Identify clinical variables of the patient
that affect SSI rates.
3. Describe care that optimizes the patient’s
condition to help prevent SSIs.

CONTENT
To what extent
4. did this article increase your knowledge
of the subject matter?
5. was the content clear and organized?
6. did this article facilitate learning?
7. were your individual objectives met?
8. did the objectives relate to the overall
purpose/goal?
TEST QUESTIONS/ANSWERS
To what extent
9. were they reflective of the content?
10. were they easy to understand?
11. did they address important points?
LEARNER INPUT
12. Will you be able to use the information
from this article in your work setting?
a. yes
b. no
13. I learned of this article via
a. the Journal I receive as an AORN
member.
b. a Journal I obtained elsewhere.
c. the AORN Journal web site.
14. What factor most affects whether you take
an AORN Journal continuing education
examination?
a. need for continuing education contact
hours
b. price
c. subject matter relevant to current posi-
tion
d. number of continuing education contact
hours offered
What other topics would you like to see ad-
dressed in a future continuing education arti-
cle? Would you be interested or do you know
someone who would be interested in writing
an article on this topic?
Topic(s): __________________________________
__________________________________________
__________________________________________
Author names and addresses: _______________
__________________________________________
__________________________________________
__________________________________________

814 • AORN JOURNAL • NOVEMBER 2007, VOL 86, NO 5 © AORN, Inc, 2007