Original Article

POST-OPERATIVE WOUND INFECTION:

A SURGEON’S DILEMMA

MASOOD AHMED, SHAMS NADEEM ALAM, OBAIDULLAH KHAN, S. MANZAR

Department of Surgery, Dow University of Health Sciences & Civil Hospital, Karachi

ABSTRACT
Objective: Keeping in view the prevalence of wound infection in our set up, this study was designed to evaluate the
frequency, clinical presentation, common risk factors and different organisms involved in cases of clean and clean-
contaminated surgery.
Design & Duration: Observational descriptive study from March 2005 to February 2006.
Setting: Surgical Unit III, Civil Hospital, Karachi.
Patients: One hundred patients who underwent clean and clean-contaminated surgery.
Methodology: Biodata of the patients together with their clinical features, diagnosis, type of surgery performed and
the development of any complications including wound infection was noted and the data analyzed.
Results: Out of the 100 patients (52 males and 48 females) in the study, 69 belonged to the clean surgery group and
31 to the clean-contaminated surgery group. The overall incidence of surgical site infection (SSI) in the study was
11%; 5(7.2%) cases in the clean surgical group and 6(19.4%) cases in the clean-contaminated group developed
infection. Patients in the age group 51-60 years were infected more than those in the younger age groups. The inci-
dence of wound infection was more in male patients (11.5%) as compared to female patients (10.4%). Obesity was
also a main cause of SSI as evident from the fact that patients with more than 60kg/m2 were infected more (20%)
as compared to 30-40kg/m2 (7.1%). Surgical site infection was found more in patients with extended pre-operative
hospital stay. Anaemia, smoking, diabetes mellitus, prolonged surgery, operations by junior surgeons and operations
late in the list were also associated with more surgical site infection. The usual time of presentation of SSI was within
three weeks following surgery and most patients presented with wound abscess and cellulitis, while two patients had
wound dehiscence. The common organisms involved in the SSI were Staphylococcus aureus, E. coli, Streptococcus
pyogenes and Pseudomonas group.
Conclusion: Meticulous surgical technique, proper sterilization, judicious use of antibiotics, improvement of operation
theatre and ward environments, control of malnutrition and obesity, treatment of infective foci and diseases like
diabetes, and avoidance of smoking helps control the morbidity of surgical wound infections.

KEY WORDS: Surgical Site Infection (SSI), Postoperative Infection, Clean Surgery, Clean-contaminated Surgery

INTRODUCTION
Infection of a wound may be defined as invasion of
organisms through tissues following a break down of
local and systemic host defences. Major wound infec-
tion is seen when a wound discharges pus and may need
a secondary procedure to be sure of adequate drainage;
there may be systemic signs or delay in return home.
In minor wound infection there is discharge of pus or
serous fluid without associated excessive discomfort
or systemic signs1.

Wound infection is the commonest and most troublesome

Correspondence:
Dr. Shams Nadeem Alam, Assistant Professor,
Department of Surgery, Dow Universirty of
Health Sciences & Civil Hospital, Karachi.
Phones: 0300-8204483.
E-mail: shamsalam@hotmail.com
disorder of wound healing2. Post operative wound infec-
tion has been a problem since surgery was started as a
treatment modality. Advancement in medicine has resul-
ted in the prevention and control of this infection. The
introduction of antiseptics is considered to be an impor-
tant mile stone on route to safe surgery. The discovery
of the antimicrobial agents also enables us to perform

41 Volume 23, Issue 1, 2007

 Post-operative Wound Infection
surgery in many conditions that were previously thought
to be impossible in the pre-antibiotic era due to the risk
of infection3.
Infection in a wound is a manifestation of disturbed
host-bacteria equilibrium that is in favour of bacteria.
This not only elicits a systemic septic response but also
inhibits the multiple processes that are involved in the
wound healing i.e. each of these processes is affected
when bacteria proliferate in a wound4.
The absolute prevention of surgical wound infection
seems to be an impossible goal. It is the second commo-
nest nosocomial infection5 and causes patient discomfort,
prolonged hospital stay, more days off work and increa-
sed cost of therapy; the cost of an operation increase
by 300% to 400%6.
An important requirement in the prevention of SSI is
the availability of correct and recent data i.e. surgical
audit and wound surveillance. Unfortunately there is a
deficiency of this topic in our local literature, and we
have to often refer to the Western studies, though the
nutritional status of their patients, operation theatre fa-
cilities, nursing care and management of wound infection
is entirely different.
This study was designed and carried out in Surgical
Unit III of Civil Hospital, Karachi in order:
1. To find out our infection rate after clean and clean-
contaminated surgery.
2. To see the clinical features of patients with SSI.
3. To find out the common organisms involved in diff-
erent wound infections.
4. To find out the risk factors for postoperative wound
infections.
Table I. Clean operations performed
Operation No.
Excision of Lipoma 6
Inguinal Hernia repair 31
Repair of other Hernias 9
Hydrocele operations 8 Cholecystectomies /
Trendelenberg operation 1 Choledocotomies
Thyroidectomy 3 Nephrectomies
Excision of Breast lump 5 Hepatic cyst excision
Mastectomy 6 Resection anastomosis
Total 69
42
PATIENTS & METHODS
This descriptive observational study was carried out
prospectively in Surgical Unit-III, Civil Hospital, Kara-
chi from March 2005 on 100 cases that underwent clean
and clean-contaminated surgery (Table I & II).
Inclusion Criteria
1. Age >14 years.
2. Patients of either sex.
3. Patients undergoing clean and clean-contaminated
surgery electively.
Exclusion Criteria
1. Refusal to participate in the study.
2. Patients already receiving antibiotics for >1 week.
3. Patients operated in emergency.
4. Patients undergoing re-operation.
5. Patients failing to come for follow-up of upto 30
days since the day of operation.
The relevant information of all the patients was entered
on a proforma especially designed for the study which
contained details about biodata, clinical features, possible
risk factors, diagnosis, complications including wound
infection, organisms isolated, hospital stay and outcome.
Since this was a descriptive study, therefore no inferential
tests were applied. The statistics were reported after
calculation by SPSS version 10.0 on computer.
RESULTS
The overall frequency of Surgical Site Infection was
11%. The incidence amongst clean surgical cases was
7.2% (5 out of 69) and amongst clean-contaminated
cases 19.4% (6 out of 31).
Age & Sex
Out of a total of 52 male patients 6 (11.5%) had SSI
Table II. Clean-contaminated
operations performed
Operation No.
23
2
1
5
Total 31
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 Post-operative Wound Infection

Age No. SSI % Quetelet Index No. SSI %

14-25 years 23 2 8.6 11-20 kg/m2 12 1 8.3

26-40 years 36 4 11.1 21-30 kg/m2 23 2 8.6
41-50 years 33 3 9.1 31-40 kg/m2 14 1 7.1
51-60 years 8 2 25.0 41-50 kg/m2 17 2 15.3
51-60 kg/m2 19 2 11.7
Table III. Age Distribution &
> 60 kg/m2 15 3 20.0
Surgical Site Infection
whilst 5 (10.4%) out of 48 female patients had SSI.
Thus it could be inferred that males were more prone Table IV. Obesity & Surgical Site Infection
to operative wound infection. Age more than 50 years site infection, proving that diabetes mellitus is a risk
was found to be a risk factor for postoperative wound for surgical site infection.
infection as shown in Table III.
Smoking
Weight & Height There were 12 smokers in the study group. Out of them
Most patients have a Quetelet Index between 20-30 3 (25%) developed SSI. On the other hand out of the
kg/m2. Obesity was more common in females and a 88 non-smokers, only eight i.e. 9.09% developed the
Quetelet index of more than 40 was identified as a risk surgical site infection.
factor for postoperative wound infection (Table IV).
Duration of Operation
Anaemia Most of the operations were completed within 60 min-
The pre-operative range of Haemoglobin level is shown utes. The rate of the surgical site infection was more in
in Table V. Pre-operative transfusions were carried out the operations that lasted more than 150 minutes (Table
to bring the level of haemoglobin to atleast 10 gms/dl. VI). The levels of TLC was seen raised in cases of the
Inspite of this correction it was noted that surgical site SSI (Tables VII).
infection was more common in patients that had low Table VI. Duration of Surgery &
haemoglobin levels pre-operatively; the more the anae- Surgical Site Infection
mia the more was the incidence of SSI.
Operation Time No. SSI %
Diabetes
Nine patients had proven diabetes mellitus in the series; < 30 mins 29 2 6.9
3 (33.33%) amongst them developed surgical site infec-
tion. In contrast to this only 8 (8.79%) out of the 91 31- 60 mins 32 3 9.4
non-diabetic patients developed postoperative surgical 61- 90 mins 25 3 12.0
Table V. Haemoglobin level & SSI 91-150 mins 10 2 20.0
(*Pre-op. transfusions to correct anaemia) > 150 mins 4 1 25.0
Hgb (gm/dl) No. SSI %
Table VII. Total Leucocyte Count in
< 08* 05 1 20.0 cases of Surgical Site Infection
08-09* 12 2 18.2 Total Leucocyte Count No. %
09-10* 14 2 14.2
10-11 24 3 12.5 < 8000 / mm3 2 18.2
11-12 27 2 7.4 8000- 11000 / mm3 1 9.1
3
12-13 14 1 7.1 11000-15000 / mm 6 52.0
3
> 13 04 -- --- 15000-20000 / mm 2 18.2

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 Post-operative Wound Infection

Sequence of Pts. No. SSI % Surgeon No. SSI %

Patient-1 45 4 8.9 Category-A 25 2 9.1

Patient-2 33 4 12.1
Patient-3 22 3 13.6
Table VIII. Incidence of SSI according to
sequence of patients on operation table
Sequence number of patients on an Operation Table
and Seniority of Surgeons
It was interesting to note that the chances of surgical
site infection were less when patients were operated as
the first case on a particular operation table (Table VIII).
The fact that the experience of the operating surgeon
affects the outcome and the incidence of infection was
also highlighted by the study, the rate of infection being
higher in patients operated by less experienced surgeons
(Table IX).
Category-A=Consultants with surgical experience of
>10 more years.
(Professors & Associate Professors)
Category-B=Consultants with surgical experience of
>5 years. (Assistant Professors &
Senior Registrars)
Category-C=Residents & PGs with 3 years experience.
Category-D=House Officers.
Category-B 27 3 10.3
Category-C 38 4 10.5
Category-D 10 2 20.0
Table IX. Seniority of Operating Surgeon
and Surgical Site Infection
tive organisms are given in Table X. The first dressing
was changed on the 3rd postoperative day or before if
the patient complained of severe pain in the wound,
there is fever or soakage of the dressing. The time of
appearance of the wound infection was within three
weeks following surgery; no patient presented in the
fourth week (Table XI). Wound dehiscence appeared
in the second post-operative week. No patient developed
septicaemia or any other life threatening condition.
Results of Culture taken from the Wound
Positive cultures were obtained from infected wounds.
The commonest bacterial isolates were Staph. aureus,
E.coli, Klebsiella, Pseudomonas and Streptococci. The
sensitivity results revealed that the Staph. aureus was
resistant to penicillin and co-trimoxazole but sensitive
to co-amoxiclav and cefuroxime.

Clinical Features of Wound Infection Noted Postoperative Hospital Stay

The pattern of wound infection and the common causa- Duration of hospital stay was increased due to develop-

Table X. Type of Surgical Site Infection & Organisms

Surgical Site Infection Common Organisms Number %

Wound abscess Staphylococcus aureus 5 45.5

Localized cellulitis Escherichia coli 3 27.7
Spreading cellulitis Streptococcus pyogenes 1 9.1
Wound dehiscence E.Coli+Klebsiella/Pseudomonas 2 18.2

Table XI. Time of Presentation of Surgical Site Infection

Time of Presentation of SSI Number Percentage

Before first dressing with fever>99.6oF or pain in the wound 1 9.1

Abscess, cellulitis or discharge noted at 1st week postoperatively 3 27.2
Abscess, cellulitis or discharge noted at 2nd week postoperatively 5 45.5
Abscess, cellulitis or discharge noted at 3rd week postoperatively 2 18.2
Abscess, cellulitis or discharge noted at 4th week postoperatively -- ---

44 Volume 23, Issue 1, 2007

 Post-operative Wound Infection
ment of wound infection. In case of localized cellulitis,
surgical intervention was not required and patients were
discharged on oral antibiotics. But when abscess develop-
ed and required surgical intervention, the patient remai-
ned in the ward for more than the expected duration;
six patients with SSI stayed between 2-5 days, three
5-10 days and two of them between 10 to 20 days.
Treatment of patients with SSI
Conservative measures were taken with minor wound
infections; three out of the 11 patients initially received
medication. One patient later developed suppuration
and needed wound drainage as with the other eight. The
stitches were removed and the wounds laid open, pus
was sent to the laboratory culture and sensitivity, and
antibiotics continued. Twice a day dressings were done
with pyodine soaked gauze packs. Finally antibiotics
were changed on receiving the sensitivity report. Nine
out of 11 patients underwent surgical intervention i.e.
drainage, secondary suturing and deep tension suturing.
There was no mortality in this study.
DISCUSSION
Despite advances in the operative techniques and better
understanding of the pathogenesis of wound infection,
postoperative wound infection continues to be a major
source of morbidity and mortality for patients undergoing
operative procedures. Its rate varies in different count-
ries, different areas and even in different hospitals. Our
overall incidence was 11%, whereas Damani described
a 30% incidence of hospital-acquired infection7. Another
study has quoted a figure of 40% in all clean and clean-
contaminated procedures, resulting in increased cost
and morbidity of the patient8.
The postoperative wound infection rate in our study
was 7.2% amongst clean surgery cases, which is higher
as the usually reported rates vary from 1% to 4%, though
most studies document a rate of less than 2%9. Our in-
fection rate for clean-contaminated cases was 19.3%.
Different studies have shown a range of 5-30% in this
class10. A study conducted at Mayo Hospital, Lahore
reported an infection rate of 5.05% in clean and 8.39%
amongst clean-contaminated cases11. Another study by
Hernandez from Peru in 2005 described rates of 13.9%
and 15.9% amongst clean and clean-contaminated cases
respectively12.
In our series the patients received prophylactic antibiotic
at the time of induction of anaesthesia in clean cases.
Single dose prophylactic antibiotic therapy is a recom-
mendation in clean cases13.
Patients with age of more than 50 years had a higher
45
incidence (25%) of postoperative wound infection in
this study as compared to 8.6% in patients having age
less than 26 years (Table III). An odd ratio for surgical
wound infection is 1.2 for every 10 years of age14. It
can be due to multiple factors like low healing rate,
malnutrition, malabsorption, increased catabolic proces-
ses and low immunity15.
Obesity is known to be a well established risk factor
for postoperative wound infection. In this study a Body
Mass Index of more than 40kg/m2 was associated with
a higher rate of postoperative wound infection (Table
IV). Obesity contributed as strongly as the surgical pro-
cedure category to a patient's likelihood of acquiring a
surgical site infection16.
Anaemia itself is not an established factor for postope-
rative wound infection. However, a higher incidence of
postoperative wound infection was noted with initial
low haemoglobin levels (Table V). It can be due to the
effect of blood transfusions, which were given preope-
ratively to bring the haemoglobin level upto 10gm/dl.
Ford et al17 postulated this in 1993.
In our study five (45.4%) patients presented with surgical
site infection in the second postoperative week, 3 (27.2%)
in the first and 3 (18.18%) in the 3rd week. Twun et al
reported that 92% of their postoperative wound infections
were detected by the 21st day18, which is comparable
to our results. In another study done at Fauji Foundation
Hospital, Rawalpindi most cases of wound infection
were noticed by the 6th postoperative day19.
The rate of postoperative wound infection in diabetic
patients was 33.33% in this study, which is significantly
higher, though sugar levels were controlled before opera-
tion by giving insulin. The increased susceptibility to
infection in diabetics is an established risk factor20.
Increased rate of surgical site infection (25%) was also
noted amongst smokers. Several studies have shown a
higher incidence of wound infection amongst smokers
than in non-smokers. It is proposed that smoking has
a detrimental effect on the tissue oxygenation, thereby
impairing the reparative processes of wound healing
and the neutrophil defense against surgical pathogens21.
The rate of postoperative wound infection was higher
(20%) amongst patients operated by junior surgeons
with lesser experience than those operated by senior
surgeons (9%) with longer experience as depicted in
Table IX. Mishriki et al reported increased infection
rates with increased duration of operation and in surgery
performed by junior residents22. The rates of infection
with individual surgeons varied from 3.9 to 14.6%23.
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 Post-operative Wound Infection
An interesting observation was that the infection rate
was significantly low when the patients were operated
as first case on a particular table. It was 8.88% for pati-
ents operated as first case, 12.12% as second case, and
13.63% as third case. Unfortunately no study in this
respect was found for comparison. However, this may
be put down to some break in the sterility of the operation
room or instruments due to increase in the number of
microflora of the OT environment due to persistent
movement of the OT staff and the surgical team, besides
the fact that senior surgeons usually perform first cases.
Regarding the duration of operation prolonged time is
a significant risk factor for postoperative wound infec-
tion23. In this study a higher incidence of postoperative
wound infection was observed when duration of opera-
tion was more than 150 minutes.
Simple wound abscess was the common presentation
in our cases. Although wound infection is the commonest
cause of dehiscence, only two cases were seen in our
series. No case of septicaemia, spreading cellulitis or
necrotizing fascitis was noted in this study. A positive
culture is not necessary for the diagnosis of wound in-
fection24. However, all our cases were cultured and re-
ported positive. Arora and colleagues25 have quoted a
figure of 87% for positive cultures.
Staphylococcus aureus has been described as the most
common single pathogen involved in postoperative
wound infections. In our series this organism was isola-
ted from 45% cases, and was sensitive to cefuroxime
and co-amoxiclav. E.coli was the second and Klebsiella
the third most common pathogen. Most of the Gram-
ve organisms were sensitive to amoxicillin, co-amoxi-
clav, cefuroxime and amikiacin.
The average postoperative hospital stay in our study
was five days in uncomplicated cases and 15 days in
cases of wound infection (range 8-25 days). Surgical
site infection delays the recovery of the patient by about
one week and in some cases significantly prolong the
duration of hospital stay26. Estimation of cost on wound
infections was not assessed by us but it was obviously
high. The approximate cost of treatment of one surgical
site infection case in the United States is $2,656 in the
year 198427.
CONCLUSION
Despite modern surgical and sterilization techniques
and prophylactic use of good antibiotics, postoperative
wound infection remains a major contributory factor of
patient’s morbidity. The overall postoperative wound
infection rate of 11% is acceptable but more attention
46
is required in clean surgical procedures where the rate
is around 5%, the universally acceptable rate being less
than 2%. This can be achieved by taking proper measures
to improve our operation theatres and wards environ-
ments, and methods of sterilization.
The common correctable risk factors are malnutrition,
obesity, presence of infective foci, diabetes, hygienic
conditions and duration of operation. These achievable
preventive measures should be taken to save the econo-
mic burden on the patient, hospital and the community
as a whole. Improper and prolonged use of antibiotics
should be avoided as it can lead to the development of
resistant strains of micro-organisms.
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