C H A P T E R 17

Surgical Site Infections

V. Ord Sarabanchong
Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY

OVERALL BOTTOM LINE

r Surgical site infections (SSIs) are associated with increased morbidity and mortality, prolonged hospital
stay, and increased cost.
r Antibiotic prophylaxis and attention to surgical risk factors can help prevent SSIs.
r Appropriate treatment can help reduce morbidity and mortality.

Background
Definition of disease
r Centers for Disease Control and Prevention (CDC) define surgical site infections as infections that occur
at or near the surgical incision within 30 days after surgery.

Disease classification
r SSIs are classified as superficial incisional (skin or subcutaneous tissue), deep incisional (fascial and
muscle layers), and involving the organ/space (tissue deeper than the muscle/fascial layer that was
opened/manipulated during surgery).

Incidence/prevalence
r Approximately 2–5% of all surgical procedures in the US are complicated by SSI.
r 2–4% of cesarean deliveries and 2% of hysterectomies in the US are complicated by SSI.
r Two-thirds of gynecologic SSIs are superficial incisional infections.

Economic impact
r An SSI can add $10 000 in excess hospital cost and prolong hospitalization by more than 4 days.

Etiology
r Microbial contamination of the surgical site is the precursor to SSI.
r SSIs related to abdominal Gyn surgery are most often infected with aerobic gram-positive cocci (Staphy-
lococcus aureus, Staphylococcus epidermidis); incisions around the groin or perineum can also involve
anaerobic bacteria and gram-negative aerobes (Enterococcus species, E. coli); incisions in the vagina
may be polymicrobial, involving aerobes and anaerobes (Enterococcus species, aerobic gram-negative
bacilli, Bacteroides species).
r SSIs related to cesarean delivery are polymicrobial: Ureaplasma species, coagulase-negative staphy-
lococci, Enterococcus faecalis, anaerobes, gram-negative rods, Staphyloccocus aureus, and group B
Streptococcus.

Mount Sinai Expert Guides: Obstetrics and Gynecology, First Edition. Edited by Rhoda Sperling.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
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136 Part 2: Gynecology

Pathology/pathogenesis
r Incision of the skin exposes tissue to endogenous flora.
r Increased microbial concentrations and altered host defenses affect the risk of SSI.

Predictive/risk factors

Risk factor Odds ratio

Host risk factors:

Obesity (body mass index ≥ 40) 2.23–2.65

Diabetes 1.4–2.5

Preoperative anemia (Hematocrit < 36%) 1.72

Tobacco use 1.99–5.32

Corticosteroid use 3.11

Bacterial vaginosis 3.2

Colonization with methicillin-resistant Staphylococcus aureus (MRSA) 12.4–25.3

American Society of Anesthesiologists class ≥ 3 1.8–5.3

Obstetrical risk factors:

Labor 1.3–4.01

Rupture of membranes 1.3–2.61

Vaginal exams 2.19

Chorioamnionitis 5.62–10.6

Nonelective vs elective cesarean 1.3–2.5

Surgical risk factors:

Duration of surgery (>75th percentile) 1.84–2.4

Abdominal skin preparation with chlorhexidine vs povidone-iodine 0.55–0.59

Intravaginal cleansing before cesarean 0.45

Antibiotic prophylaxis 0.4

Manual removal of placenta 1.64

Subcutaneous tissue closure 0.68

Hyperglycemia 1.4–9.4

Preoperative disinfection 0.36

Normothermia 0.36

Preoperative hair shaving vs clipping 2.09

Abdominal hysterectomy vs laparoscopic/vaginal 2.0–3.74

Prevention

BOTTOM LINE/CLINICAL PEARLS

r Prevention of SSIs focuses on addressing modifiable risk factors.
r Antibiotic prophylaxis, management of comorbid conditions, appropriate operative technique, and
surgical site preparation can help prevent SSIs.
 Surgical Site Infections 137

Primary prevention
r Remote infection such as skin or urinary tract infection should be treated before elective surgery, or
surgery should be postponed until the infection has resolved.
r Consider preoperative screening for bacterial vaginosis before hysterectomy.
r Advise patients to shower or bathe with soap (preferably chlorhexidine) on at least the night before
surgery.
r Do not shave the incision site; when hair removal is necessary, clippers rather than a razor should be
used immediately before the procedure.
r Chlorhexidine-alcohol, rather than povidone-iodine, should be used to clean the skin before
incision.
r 4% chlorhexidine or povidone-iodine should be used to clean the vagina before hysterec-
tomy, vaginal surgery, and before cesarean delivery in laboring patients or those with ruptured
membranes.
r Implement perioperative glycemic control with target levels of blood glucose less than 200 mg/dL for
diabetic and nondiabetic patients.
r Maintain perioperative normothermia.
r The placenta should be removed by manual traction rather than manual extraction.
r Abdominal wounds greater than 2 cm in depth should be closed with a running suture.
r Use appropriate prophylactic antibiotics.

Procedurea Antibiotic Doseb

Cesarean delivery Cefazolin 1 g IV

(2 g IV for weight greater than 80 kg,
3 g IV for weight greater than 120 kg)
Clindamycinc plus 900 mg IV
gentamicin 5 mg/kg IV

Hysterectomy, colporrhaphy, vaginal sling Cefazolin 2 g IV

placement; consider for laparotomy without (3 g IV for weight greater than 120 kg)
bowel/vaginal entry or vulvectomy Clindamycinc plus 900 mg IV
gentamicin or 5 mg/kg IV
aztreonam 2 g IV
Metronidazolec plus 500 mg IV
gentamicin or 5 mg/kg IV
aztreonam 2 g IV

Induced abortion/dilation and evacuation Doxycycline 200 mg orally 1 hour before procedure

Hysterosalpingography (HSG), Doxycycline 100 mg orally twice daily for 5 days

chromopertubationd

Repair of obstetric anal sphincter injuries Cefotetan or 1 g IV

Cefoxitin or 1 g IV
Clindamycin[c] 900 mg IV
a Antibiotic prophylaxis is not recommended for diagnostic or operative laparoscopy or hysteroscopy.
b Administration of IV antibiotics is within 1 hour of incision. Single-dose therapy is recommended. Redos-
ing is recommended if surgery exceeds the following durations: 4 hours for cefazolin or aztreonam; 6 hours
for clindamycin; metronidazole and gentamicin are not redosed. Redosing of IV antibiotics is recommended
if blood loss exceeds 1500 mL.
c Recommended for patients with an immediate hypersensitivity to penicillin. For gentamicin dosing, in patients weigh-

ing > 20% above ideal body weight (IBW), body weight calculations are adjusted as follows: weight in kg = IBW + 0.4
(actual weight-IBW).
d
Antibiotic prophylaxis is recommended only for patients with a history of PID or abnormal tubes noted on HSG or
laparoscopy.
138 Part 2: Gynecology

Diagnosis

BOTTOM LINE/CLINICAL PEARLS

r The diagnosis of SSI is based on history and physical exam findings suggestive of infection.
r Blood tests, wound culture, and imaging can help establish the severity and extent of infection, thus
guiding treatment.

Differential diagnosis

Differential diagnosis Features

Urinary tract infection Pain may be localized to the pelvis, but dysuria and/or frequency of urination are
key features. Urinalysis will reveal leukocytes, blood, or bacteria.

Wound seroma/hematoma Localized pain and swelling at the incision that may be accompanied by
spontaneous drainage. The fluid drained will be sterile.

Retained products of Persistent pain and bleeding following surgical abortion, with blood and debris
conception seen in the endometrial cavity on ultrasound. Can be further complicated by
infection of the retained products, with resulting fever, leukocytosis, and possible
sepsis.

Septic pelvic thrombophlebitis Typically, postpartum presentation of fever, leukocytosis, with or without
abdominal pain, unresponsive to antibiotics. Computed tomography (CT) or
magnetic resonance imaging (MRI) sometimes demonstrates thrombus.
Anticoagulation is necessary for resolution.

Appendicitis, diverticulitis Localized pain, nausea, possible change in bowel habits; diagnosis best
differentiated by CT imaging.

Typical presentation
r Superficial and deep incisional SSIs will present with pain, redness, and swelling at the incision at least 2
days after surgery; there may be purulent drainage. Organ/space SSIs can present with abdominal/pelvic
pain, fever, and possibly a tender pelvic mass on physical exam.

Clinical diagnosis
History
r History should focus on onset of symptoms (usually 48 hours after surgery but most often 5 days
postoperatively), and any associated symptoms, such as nausea/vomiting or change in bowel or urinary
habits.

Physical examination
r Classic indicators of infection should be assessed: fever (calor) defined as a temperature of 38 °C or
higher on two separate occasions taken at least 6 hours apart, or an isolated temperature of 38.3 °C;
swelling (tumor); and erythema (rubor) at or near the incision. Tachycardia may be present.
r Exam may reveal purulent drainage at the incision or a tender mass on pelvic exam; there may be fundal
tenderness if the uterus has not been removed.

Disease severity classification

r Superficial incisional SSI: involving skin or subcutaneous tissue.
r Deep incisional SSI: involving fascial and muscle layers.
 Surgical Site Infections 139

r Organ/space SSI: involving tissue deeper than the muscle/fascial layer that was opened or manipulated
during surgery.

Laboratory diagnosis
List of diagnostic tests
r Complete blood count: an elevated white blood count with a left shift suggests an acute infection.
r Metabolic panel: assessment of renal function and acidemia in the setting of infection.
r Gram stain and culture of wound drainage: bacterial identification and sensitivities will guide antibiotic
selection.

List of imaging techniques

r Imaging may be obtained if physical examination fails to localize the SSI.
r Pelvic ultrasound is often the first choice and can identify superficial and deep pelvic fluid collections as
well as retained products of conception.
r CT imaging with contrast is particularly useful for visualizing pelvic abscesses or evaluating for perforated
viscus.

Potential pitfalls/common errors made regarding diagnosis of disease

r Fever in the immediate 48 hours after surgery is less likely due to infection and most often due to
atelectasis or pyogenic cytokine release.
r Beyond 48 hours after surgery, other common sources for fever such as urinary tract infection, deep
venous thrombosis, and pneumonia should be considered.

Treatment
Treatment rationale
r Superficial SSI can often be managed with oral antibiotics.
r The presence and amount of purulent drainage may necessitate opening the wound for debridement.
r Deep incisional and organ/space SSI may require IV antibiotics, percutaneous pelvic drain placement, or
surgical exploration.

When to hospitalize
r Patients with peritonitis, pelvic abscess, or signs of sepsis or who require IV antibiotics should be
admitted.

Managing the hospitalized patient

r IV antibiotics should be administered until afebrile for 24–48 hours and then transitioned to oral
antibiotics.
r For postpartum endometritis, additional treatment with oral antibiotics has not been found to be
beneficial.
r For pelvic abscess, CT or ultrasound-guided percutaneous drainage should be considered for size > 8 cm
diameter, or if fevers persist beyond 48 hours of treatment with IV antibiotics.
r Surgical exploration may be necessary if conservative measures fail, if there is clinical deterioration or
sepsis, for ruptured abscess or perforated viscus, or for necrotizing fasciitis.
r See Algorithm 17.1.
140 Part 2: Gynecology

Algorithm 17.1 Management/treatment of surgical site infections

Oral antibiotics plus wound

Superficial SSI
debridement for purulent drainage.

IV antibiotics. Pelvic abscess >8 Inadequate response after 48 hours

Deep incisional and
cm should have CT or ultrasound- should prompt reimaging, broadening
organ/space SSI
guided percutaneous drainage. antibiotics, or surgical intervention.

Table of treatment

Treatment Comments

Medical

Superficial SSI: Duration of treatment is 7–14 days.

Dicloxacillin 500 mg PO every 6 h.
Trimethoprim-sulfamethoxazole 160–800 mg PO every 12 h (for
suspected MRSA).
Amoxicillin-clavulanate 875–125 mg PO every 12 h (for vaginal cuff
cellulitis).
Deep incisional and organ/space SSI: Duration of treatment is 14 days.a
Gentamicin 5 mg/kg every 24 h plus clindamycin 900 mg every 8 h.
Ceftriaxone 2 g IV every 24 h plus metronidazole 500 mg every 12 h.
Piperacillin-tazobactam 3.375 g IV every 6 h.
Vancomycin 20 mg/kg IV every 12 h (can be added to the above
regimens for suspected MRSA).

Surgical

Wound debridement May be necessary for purulent drainage.

Laparoscopy or exploratory laparotomy May be necessary if conservative measures
fail, if there is clinical deterioration or sepsis,
for ruptured abscess or perforated viscus, or
for necrotizing fasciitis.

Radiological

CT or ultrasound-guided percutaneous drainage For abscess > 8 cm or abscess not responding

to IV antibiotics after 48 hours treatment.
a
Postpartum endometritis is treated with IV antibiotics until afebrile for 24–48 h. Pelvic abscess may require more than
14 days treatment depending on resolution of abscess.

Prevention/management of complications
r Necrotizing fasciitis is a rare polymicrobial complication of wound infection that can spread rapidly along
the fascial planes and subcutaneous tissue.
r Clostridium and group A Streptococcus are frequently involved, producing crepitation on physical exam
or gas in the subcutaneous tissue on imaging.
r Mean time to diagnosis is 10 days from surgery, with mortality as high as 50%.
r Mainstays of treatment are extensive debridement and broad-spectrum antibiotics.

CLINICAL PEARLS
r Prompt recognition and initiation of appropriate antibiotics are key to treating SSI.
r Clinical presentation or lack of improvement should prompt wound debridement, pelvic imaging,
broadened antibiotics, percutaneous drainage, or surgical intervention.
 Surgical Site Infections 141

Special populations
r Patients with known MRSA colonization or at high risk for MRSA colonization (e.g. nursing home resi-
dents, hemodialysis patients) should have vancomycin (15 mg/kg) added to the preoperative antibiotic
prophylaxis regimen. Universal screening for MRSA is not recommended.
r Patients receiving therapeutic antibiotics for infection before surgery should be administered an extra
dose 60 minutes before surgical incision if the agents used are appropriate for surgical prophylaxis.
r Patients with bacterial vaginosis who are undergoing hysterectomy, vaginal surgery, or surgical abortion
should be treated preoperatively.

Prognosis

BOTTOM LINE/CLINICAL PEARLS

r Prompt and appropriate treatment of SSI can shorten hospital stay and reduce morbidity and mortality.

Reading list
Bakkum-Gamez JN, Dowdy SC, Borah BJ, et al. Predictors and costs of surgical site infections in patients with endometrial
cancer. Gynecol Oncol 2013 Jul;130(1):100-6.
Black JD, de Haydu C, Fan L, et al. Surgical site infections in gynecology. Obstet Gynecol Surv 2014 Aug;69(8):
501-10.
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.
N Engl J Med 2010 Jan 7;362(1):18-26.
Duggal N, Mercado C, Daniels K, et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complica-
tions: a randomized controlled trial. Obstet Gynecol 2008 Jun:111(6):1268-73.
Fitzwater JL, Tita AT. Prevention and management of cesarean wound infection. Obstet Gynecol Clin North Am 2014
Dec;41(4):671-89.
Kao LS, Phatak UR. Glycemic control and prevention of surgical site infection. Surg Infect (Larchmt) 2013 Oct;14(5):
437-44.
Lachiewicz MP, Moulton LJ, Jaiyeoba O. Pelvic surgical site infections in gynecologic surgery. Infect Dis Obstet Gynecol
2015;2015:614950.
Lake AG, McPencow AM, Dick-Biascoechea MA, et al. Surgical site infection after hysterectomy. Am J Obstet Gynecol
2013 Nov;209(5):490.e1-9.
Mittendorf R, Aronson MP, Berry RE, et al. Avoiding serious infections associated with abdominal hysterectomy: a
meta-analysis of antibiotic prophylaxis. Am J Obstet Gynecol 1993 Nov;169(5):1119-24.
Opøien HK, Valbø A, Grinde-Andersen A, et al. Post-cesarean surgical site infections according to CDC standards: rates
and risk factors. A prospective cohort study. Acta Obstet Gynecol Scand 2007;86(9):1097-102.
Steiner HL, Strand EA. Surgical-site infection in gynecologic surgery: pathophysiology and prevention. Am J Obstet
Gynecol 2017 Aug;217(2):121-28.
Zuarez-Easton S, Zafran N, Garmi G, et al. Postcesarean wound infection: prevalence, impact, prevention, and manage-
ment challenges. Int J Womens Health 2017 Feb 17;9:81-88.

Suggested websites
American College of Obstetricians and Gynecologists. www.ACOG.org
American Society of Hospital Pharmacists. www.ASHP.org
Centers for Disease Control and Prevention. www.CDC.gov
The Joint Commission. www.JointCommission.org
142 Part 2: Gynecology

Guidelines
National society guidelines

Title Source Date/URL

Prevention of infection after ACOG June 2018

gynecologic procedures: https://www.acog.org/Clinical-Guidance-and-
ACOG practice bulletin no. Publications/Practice-Bulletins/Committee-on-
195. Practice-Bulletins-Gynecology/Prevention-of-
Infection-After-Gynecologic-Procedures

Use of prophylactic antibiotics ACOG August 2018

in labor and delivery: ACOG https://www.acog.org/Clinical-Guidance-and-
practice bulletin no. 199. Publications/Practice-Bulletins/Committee-on-
Practice-Bulletins-Obstetrics/Use-of-Prophylactic-
Antibiotics-in-Labor-and-Delivery

Prevention of surgical site Centers for Disease Control 2017

infection and Prevention http://jamanetwork.com/journals/jamasurgery/
fullarticle/2623725

Clinical practice guidelines American Society of 2013

for antimicrobial prophylaxis Health-System Pharmacists https://academic.oup.com/ajhp/article/70/3/195/
in surgery (ASHP) Therapeutic 5112717?sso-checked=true
Guidelines.

Evidence
Type of evidence Title and comment Date/URL

Systematic review Cochrane Database. 2016 Apr 21

Active body surface warming systems https://www.ncbi.nlm.nih.gov/pubmed/27098439
for preventing complications caused by
inadvertent perioperative hypothermia
in adults.

Systematic review Cochrane Database. 2015 Feb 20

Preoperative bathing or showering https://www.ncbi.nlm.nih.gov/pubmed/25927093
with skin antiseptics to prevent surgical
site infection.

Systematic review Cochrane Database. 2015 Feb 2

Antibiotic regimens for postpartum https://www.ncbi.nlm.nih.gov/pubmed/25922861
endometritis.

Systematic review Cochrane Database. 2014 Dec 21

Vaginal preparation with antiseptic https://www.ncbi.nlm.nih.gov/pubmed/25528419
solution before cesarean delivery for
preventing postoperative infections.

Systematic review Cochrane Database. 2011 Nov 9

Preoperative hair removal to reduce https://www.ncbi.nlm.nih.gov/pubmed/22071812
surgical site infection.