SURGICAL INFECTIONS

Volume 7, Supplement 1, 2006

© Mary Ann Liebert, Inc.
DOI: 10.1089/sur.2006.7.s1-7

Risk Factors for Surgical Site Infection

WILLIAM G. CHEADLE

ABSTRACT

Background: As many as 5% of patients undergoing surgery develop surgical site infections

(SSIs), which may cause much morbidity and may sometimes be fatal. Treating SSIs imposes
a substantial strain on the financial resources of the health care system.
Methods: Review of current practice and guidelines.
Results: Important patient-related factors for SSI include existing infection, low serum al-
bumin concentration, older age, obesity, smoking, diabetes mellitus, and ischemia secondary
to vascular disease or irradiation. Surgical risk factors include prolonged procedures and in-
adequacies in either the surgical scrub or the antiseptic preparation of the skin. Physiologi-
cal states that increase the risk of SSI include trauma, shock, blood transfusion, hypothermia,
hypoxia, and hyperglycemia. Parameters that may be associated independently with an in-
creased risk of SSI, and that may predict infection, include abdominal surgery, a contami-
nated or dirty operation, and more than three diagnoses at the time of discharge. The major
sources of infection are microorganisms on the patient’s skin and, less often, the alimentary
tract or female genital tract. The organism most often isolated is Staphylococcus aureus, which
often is resistant to methicillin. Antibiotic-resistant bacteria are a continuing and increasing
problem.
Conclusions: A wide range of patient-related, surgery-related, and physiological factors
heighten the risk of SSI.

S URGICAL SITE INFECTIONS (SSIs) run the gamut

from small suture abscesses that are easily
managed to massive and persistent infections
that may alter a patient’s life, perhaps perma-
nently. According to the 1999 guidelines of the
U.S. Centers for Disease Control and Preven-
tion (CDC), more than 30 million operations are
done each year at U.S. hospitals [1]. Reported
rates of SSI range from 2% to 3%, but these fig-
ures probably underestimate the true rate. In-
fections may total three-fourths of a million an-
nually, two-thirds of which are limited to the
incision. The Department of Veterans Affairs
has monitored surgical infections over the past
two decades, and the continuity of care and
close followup add legitimacy to their figure of
5.1%. For comparison, the rates of pneumonia,
urinary tract infection, and systemic sepsis are
3.6%, 3.5%, and 2.1%, respectively [2]. Roughly
2% of surgical patients are seriously ill. Surgi-
cal site infection accounts for as many as one-
fourth of all nosocomial infections and is the
most common cause of such infections in sur-
gical patients. The microorganism most often
isolated is Staphylococcus aureus, which often is
resistant to methicillin (MRSA).

Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky.

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PATHOGENESIS
The patient, the infecting organism, and the
procedure itself all create risks for infection.
The CDC guidelines formulate the risk of SSI
as the size of the bacterial inoculum (contami-
nation) multiplied by bacterial virulence, the
product being divided by host resistance [1].
What formerly were called wound infections
have been redefined as SSIs and categorized as
superficial incisional (involving the skin and sub-
cutaneous fat), deep incisional (involving fascia
and muscle), and organ or space (Fig. 1).
RISK FACTORS: THE PATIENT
A long list of potential patient risk factors for
SSI has been identified, but few have been con-
firmed as such in randomized clinical trials. A
low serum albumin concentration is viewed as
an important risk factor because it signifies a
wide range of comorbid conditions that render
the patient nutritionally impaired or immuno-
compromised. Other important factors are age,
ischemia secondary to vascular disease, dia-
betes mellitus, or radiation; diabetes itself;
smoking; and obesity. Existing infection should
be treated before elective surgery is under-
taken. Colonization by MRSA often leads to an-
FIG. 1. Types of SSI. Reprinted from Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of sur-
gical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27:97–134.
(Reprinted with permission from Association for Professionals in Infection Control and Epidemiology, Inc.)
CHEADLE
other infection, especially in elderly patients
and nursing home residents. The length of the
preoperative hospital stay is a much less sig-
nificant problem than in former years. Im-
paired lymph flow was a greater problem when
axillary and groin dissections were common in
the treatment of cancer.
RISK FACTORS: THE OPERATION
The duration of the surgical scrub and the
skin antiseptic preparation influence the risk of
SSI. The length of the operation also is impor-
tant; procedures longer than 3–4 h increase the
risk.
Body hair at the site of the incision was long
considered to increase risk because of exposure
of the surgical site to bacteria on the hair. In re-
cent years, however, hair entering the wound
has not been considered a major source of con-
tamination by most surgeons, and efforts to re-
move body hair are considered only when it is
excessive.
Antimicrobial prophylaxis is important, as is
proper ventilation of the operating room (in-
cluding fresh air exchanges). It is not worth-
while to flash-sterilize a dropped instrument
unless it clearly is essential to complete the op-
eration. Any foreign material at the surgical site
RISK FACTORS FOR SURGICAL SITE INFECTION
can dispose the patient to infection. Surgical
drains are appropriate only if drainage is ex-
pected; a drain incites an inflammatory response
and can make an anastomosis leak. High-qual-
ity surgical technique means handling tissues
gently, not leaving hematomas, and eliminating
dead space as far as is possible. Exposure to
hemoglobin may increase bacterial infectivity
through suppression of phagocytosis.
RISK FACTORS: THE MICROBE
Endogenous microorganisms implicated in
SSI come chiefly from the patient’s skin and,
less often, the alimentary tract or female geni-
tal tract. Exogenous microbes potentially come
from the operator’s hands, the instruments, or
the ambient air. As is S. aureus, enteric organ-
isms are relatively virulent. Less virulent mi-
crobes include coagulase-negative staphylo-
cocci and Bacteroides spp.
The famed Hungarian physician Ignacz Sem-
melweis, who practiced obstetrics in Austria in
the mid-19th Century, anticipated Pasteur’s
germ theory by recognizing the need to wash
one’s hands (especially when going from dis-
secting cadavers to examining expectant
women) and to soak his instruments in anti-
septic solution. Although his peers failed to
adopt these measures, the prevailing rate of
postpartum endometritis, which had been ex-
tremely high, decreased markedly in his pa-
tients, to an estimated 5%.
HOST DEFENSES
The complexity and redundancy of the im-
mune system make it difficult to quantify im-
mune function. Nevertheless, it is clear that
some individuals are more susceptible than
others to infection. Conditions that may impair
immune function include diabetes mellitus,
malnutrition, obesity, chronic illness in general,
and administration of immunosuppressive
drugs. Among the physiological states that ren-
der the host more susceptible to infection are
trauma, shock, blood transfusion, hypother-
mia, hypoxia, and hyperglycemia. Factors re-
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lated to the surgical site itself that are likely to
promote infection include the presence of
hematoma, the use of epinephrine, and exces-
sive application of cautery, which results in a
large volume of necrotic tissue.
PREDICTORS OF SSI
The Study on Efficacy of Nosocomial Infec-
tion Control (SENIC) trial assessed the effec-
tiveness of various measures in the years
1976–1988 [3]. Four parameters were indepen-
dent markers of a higher risk of SSI: Abdomi-
nal surgery, surgery lasting longer than two
hours, a contaminated or dirty procedure, and
more than three diagnoses at the time of dis-
charge. This predictive method proved to be
more accurate than the long-standing practice
of surgeons of making risk predictions on the
basis of their personal experience.
A similar attempt to identify factors predic-
tive of SSI was the National Nosocomial Infec-
tion Surveillance (NNIS) study [4,5], begun in
1970 and continuing to the present time. The
three crucial factors identified were an Ameri-
can Society of Anesthesiologists (ASA) score of
3 or more on a 5-point scoring system, a con-
taminated or dirty procedure, and an operation
lasting longer than the 75th percentile of the av-
erage duration for that procedure. The NNIS
system may be used to formulate a risk cate-
gorization index ranging from 0 to 3, where 1
point each is assigned for an ASA score of 3 to
5, a contaminated or dirty/infected wound,
and prolonged operating time [4,5]. The risks
for SSI associated with different index scores
are: 0  1.5%; 1  2.9%; 2  6.8%; and 3  13%.
PREVENTING SSI
The foundation of any strategy to decrease
the risk of SSI is proper patient preparation and
sound surgical technique. In the last several
years, accumulating evidence has shown that
regulation of three host defense factors—body
temperature, oxygenation, and blood sugar—
are important in determining the risk of SSI in
a given patient. The risk of infection increases
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if normal body temperature is not maintained
[6], blood sugar is not controlled [7,8], or oxy-
genation is inadequate [9]. Patients who are
malnourished should have enteric feeding or,
if necessary, total parenteral nutrition if exten-
sive surgery is planned.
An established infection increases the risk of
SSI and should be treated prior to operation. Far
more antibiotics are used to prevent infections
than to treat them. There is wide agreement that
antimicrobial prophylaxis should be given 30 to
60 min before the incision is made. For prolonged
operations, additional doses should be given to
ensure that adequate tissue concentrations are
present throughout the case. Appropriate use of
antibiotics is especially important for patients at
increased risk of SSI such as those having oper-
ations on the alimentary tract or cardiac and or-
thopedic operations and those having a pros-
thesis implanted. Although the overall risk of
infection is low in most patients, when it does
occur, the consequences may be disastrous.
A major problem with antimicrobial pro-
phylaxis is that many surgeons do not follow
recommended guidelines. Even when drugs
are administered appropriately, all bacteria are
not killed (the incision site is not sterilized), and
antibiotics are much less effective in the ab-
sence of other prophylactic measures. In addi-
tion, bacterial resistance to the penicillins, van-
comycin, and other antimicrobials is a problem
that will only get worse.
In the National Surgical Infection Prevention
Collaborative [10], infection rates were ana-
lyzed in approximately 35,000 surgical patients
at 56 hospitals over a 12-month period. Infec-
tion risk in the first three months was com-
pared with that in the last three months, dur-
ing which time, antimicrobial prophylaxis was
supervised closely and normothermia, proper
oxygenation, and euglycemia were maintained
carefully. Appraisal of prophylaxis took into
account the particular antimicrobial agent cho-
sen and the timing and duration of treatment.
In addition, clipping replaced preoperative
shaving. The initial infection rate of 2.3% de-
creased to 1.7% in the last three months of the
study. Although this may not seem to be a ma-
jor change, it is a significant benefit consider-
ing the large number of patients at risk and the
large reduction in costs of treating SSI.
CHEADLE
CONCLUSION
Surgical site infection is not a rare complica-
tion: Probably more than 3% of surgical pa-
tients are affected. Although many incisional
infections are controlled easily, deeper and
more extensive infections may have devastat-
ing consequences. Patient factors, including
immune function, body temperature, oxygena-
tion, glycemic control, the particular surgical
procedure carried out, and the infecting or-
ganism, all may pose risks for SSI. Antimicro-
bial prophylaxis, although important, does not
itself prevent or reduce the risk of SSI. Good
surgical technique is essential; local measures
other than antisepsis may prove to be part of
the solution to the problem of SSI.
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RISK FACTORS FOR SURGICAL SITE INFECTION S-11

9. Belda JF, Aguilera L, Asuncion JG, et al. Supplemen- Address reprint requests to:
tal perioperative oxygen and the risk of surgical Dr. William G. Cheadle
wound infection: A randomized controlled trial.
Department of Surgery
JAMA 2005;294:2035–2042. Erratum in: JAMA 2005;
294:2973. University of Louisville School of Medicine
10. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hos- Louisville, KY 40292
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Am J Surg 2005;190:9–15. E-mail: wg.cheadle@louisville.edu