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evidence-based Infections, Surgical Site: Prevention

Care Sheet

What We Know
 Surgical site infections (SSIs) are the most common hospital-acquired infections in surgical patients in
the United States, totaling about 1 million per year(1, 4)
 SSIs are associated with increased patient morbidity and mortality, and increased length of hospital stay
and hospital costs(1, 2, 3, 4, 7)
•• Mortality rate is twice as high in adult patients with SSIs, and 4 times greater in older patients
suffering from SSIs(3)
 SSI symptoms usually present within 1 week to 30 days after surgery and can include purulent drainage
at the incision site, fever, wound abscess, pain on palpation, and localized pain, tenderness, swelling,
redness, and warmth(4, 8)
 Cultures of fluid and/or tissue from the site of incision are used to confirm the cause of SSIs. SSIs are
most commonly caused by Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus
species, and Escherichia coli. Drug-resistant bacteria include methicillin-resistant S. aureus (MRSA).
Infections caused by Candida albicans and other Candida species (yeasts) can develop in preexisting
surgical infections of patients who received treatment with broad-spectrum antibiotics(1, 2, 4, 8)
 Risk factors(1, 2, 4, 6, 7, 8)
•• Patient risk factors
–– Diabetes mellitus, poor nutritional status, older age, cigarette smoking, steroid use, obesity, and
blood transfusions increase the risk of SSI
–– Patients with chronic illness, coexisting infections at other sites, nares that are colonized with
S. aureus, and/or who are severely ill are at increased risk for SSI
–– SSI usually develops from a patient’s normal flora, rather than from environmental sources
•• Surgical risk factors
–– Inadequate antiseptic shower or bath, inadequate skin preparation, and lack of antimicrobial
–– Preoperative hair removal resulting in cuts on the skin in which bacteria may grow
Jennifer Kornusky, RN, MS –– Inadequate operating room ventilation, poor sterilization of surgical equipment and environmental
Sara Grose, MSN, RN, PHN, CNL, CLE surfaces, lack of or improper use of surgical barriers, compromised aseptic technique, breaks in
surgical technique, prolonged duration of surgical procedure, and hypothermia
Gilberto Cabrera, MD •• Surgical personnel risk factors
Cinahl Information Systems –– Surgical personnel infected or colonized with bacteria and/or who use poor handwashing techniques
Glendale, California
•• Postoperative risk factors
Darlene A. Strayer, RN, MBA –– Poor wound management and inadequate patient education upon discharge
Cinahl Information Systems  SSIs may be superficial incisional, when infection compromises only superficial layers of skin or
Glendale, California subcutaneous tissue; deep incisional, if deeper layers (e.g., fascia and muscle) are involved; or organ/
Nursing Practice Council
space SSI, if they compromise organs or spaces that were incised or manipulated during surgery(6)
Glendale Adventist Medical Center  The National Research Council (NRC) of the U.S. National Academy of Sciences classifies incisions based
Glendale, California on degree of bacterial contamination; the higher the classification number, the higher the risk of SSI(1, 4)
•• Classifications
Diane Pravikoff, RN, PhD, FAAN –– Class I – clean (uninfected, no inflammation encountered)
Cinahl Information Systems –– Class II – clean contaminated (respiratory, genital, or urinary tract are entered/compromised)
–– Class III – contaminated (open accidental wound, broken sterile technique, GI tract spillage)
–– Class IV – dirty-infected (existing infection, old wound with dead tissue present)
April 9, 2010  The American Society of Anesthesiologists (ASA) uses a point system ranging from 1–6 to assess patient

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from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a
general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
risk factors for SSI preoperatively; a higher number suggests a higher risk of SSI(4)
 The National Nosocomial Infections Surveillance (NNIS) has created a risk stratification index score to determine the risk of SSI. The index score
is based on the ASA patient classification score, the NRC classification score, and a score based on the length of the surgical procedure(4)
 Prevention of SSI includes the use of prophylactic antibiotics, proper aseptic and surgical techniques, adequate sterilization of instruments and
surfaces, and appropriate pre-, intra-, and postoperative care of the patient(1, 4, 8)
•• Preoperative care includes appropriate diagnosis and treatment of infections before surgery, hair removal at incision site only when necessary,
and immediately before the procedure; glycemic control; smoking cessation at least 30 days before the procedure
•• Operative care of the patient also includes proper skin preparation, aseptic techniques, and antiseptic practices before and during the procedure
 Depending on the severity of the SSI, treatment may include wound drainage and/or debridement and the use of antibiotics(2, 6)
 One study showed that patients receiving 30% supplemental oxygen during surgery were not at lower risk for developing SSI compared to patients
receiving 30% supplemental oxygen during surgery(5)

What We Can Do
 Learn about SSIs (including signs and symptoms; risk factors for different types of surgeries; how to classify incisions; and what to do before,
during, and after surgery to prevent SSIs) so you can accurately assess your patients’ personal characteristics and health education needs. Share this
knowledge with your colleagues
 Become familiar with the NNIS risk stratification scoring system
 Take a comprehensive history of presurgical patients and thoroughly assess risk factors
•• Surgery may need to be postponed if coexisting conditions and/or infections are not treated(4)
 Before surgery(4, 8)
•• Prepare patient for surgery according to facility presurgical protocols. These may include having the patient shower or bathe with antiseptic soap
the night before the surgery; monitoring glucose levels; continuing with any preoperative blood transfusions; removing hair, if necessary, with
electric clippers immediately before surgery; proper cleansing of the incision area and application of antiseptic agents (e.g., chlorhexidine); and
administering prescribed antibiotic prophylaxis (e.g., cefazolin, cefoxitin), usually within 1 hour of the surgical incision and during surgery if the
procedure is lengthy (a notable exception is vancomycin, which may require a longer presurgical infusion time). Intranasal mupirocin may be
used to eliminate nasal colonization of bacteria. Some procedures require emptying the bowel using enemas and cathartic agents
•• Report any signs/symptoms of presurgical infection to the treating clinician/surgeon
 After surgery – note size, location, color, depth, temperature, and condition of incision; inspect for purulent drainage; monitor culture and Gram
stain results; using aseptic techniques, apply appropriate sterile dressing, keep dry and intact, and change dressing often(1, 4)
 Notify the surgeon if SSI is suspected
 Follow facility protocols for surveillance programs to prevent, monitor, and control SSI
 Written aftercare instructions should be provided to patient and/or family or caregiver to reinforce verbal education; encourage patient to verbalize
understanding of instructions. Inform patient of signs of SSI and when to seek medical attention(4)

Coding Matrix References

References are rated in order of strength: 1. Casper, P. B., Joshi, M., & Algire, M. C. (2009). Infection and infection control. In K. A. McQuillan, M. B. F. Makic, & E. Whalen (Eds.), Trauma nursing: From
M Published meta-analysis resuscitation through rehabilitation (4th ed., pp. 268-271). St. Louis: Saunders, Elsevier. (GI)
SR Published systematic or integrative literature review 2. Gravante, G., Caruso, R., Araco, A., & Cervelli, V. (2008). Infections after plastic procedures: Incidences, etiologies, risk factors and antibiotic prophylaxis. Aesthetic
RCT Published research (randomized controlled trial) Plastic Surgery, 32(2), 243-251. (RV)
R Published research (not randomized controlled trial) 3. Kaye, K. S., Anderson, D. J., Sloane, R., Chen, L. F., Choi, Y., Link, K.,… Schmader, K. E. (2009). The effect of surgical site infection on older operative patients.
Journal of the American Geriatrics Society, 57(1), 46-54. (R)
C Case histories, case studies
4. Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of surgical site infection, 1999. Hospital Infection Control
G Published guidelines
Practices Advisory Committee. Infection Control and Hospital Epidemiology: The Official Journal of the Society of Hospital Epidemiologists of America, 20(4), 250-280. (G)
RV Published review of the literature 5. Meyhoff, C. S., Wetterslev, J., Jorgensen, L. N., Henneberg, S. W., Høgdall, C., Lundvall, L., … Rasmussen, L. S. (2009). Effect of high perioperative and oxygen
RU Published research utilization report fraction on surgical cite infection and pulmonary complications after abdominal surgery: The PROXI randomized clinical trial. JAMA: Journal of the American Medical
QI Published quality improvement report Association, 302(14), 1543-1589. (RCT)
L Legislation 6. Mundy, L. M., Doherty, G. M., & Perren Cobb, J. (2006). Inflammation, infection & antimicrobial therapy. In G. M. Doherty & L. W. Way (Eds.), Current surgical
diagnosis and treatment (12th ed., pp. 97, 102-103). New York: Lange Medical Books/McGraw-Hill. (GI)
PGR Published government report
7. Rao, N., Cannella, B., Crossett, L. S., Yates, A. J., Jr., & McGough, R., III. (2008). A preoperative decolonization protocol for Staphylococcus aureus prevents
PFR Published funded report
orthopaedic infections. Clinical Orthopaedics and Related Research, 466(6), 1343-1348. (R)
PP Policies, procedures, protocols 8. Tanner, J., & Khan, D. (2008). Surgical site infections, preoperative body washing and hair removal. Journal of Perioperative Practice, 18(6), 232, 237-243. (RV)
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster
presentations or other such materials
CP Conference proceedings, abstracts, presentations