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A Nurse’s Story 

“In my second semester of nursing school, I took care of a patient who had open–heart surgery. I was the nursing nurse assigned to him and got to discharge him that day. Everything seemed to go well. He was progressing well, and he and his family were excited he was going home. A few weeks later, I was shadowing in the intensive care unit (ICU) and was shocked to see my same patient laying before me on a ventilator and on multiple IV medications.  

The ICU nurse worked swiftly, and I stood in awe of her ability to monitor the many machines he needed in order to survive. It was eerily quiet in the ICU, and the nurse pulled me aside to let me know that the patient was not going to make it that day and he would probably die sometime in the afternoon. I wondered, why? What would cause this man, who I had discharged from the hospital just a few weeks, to get to the point of dying?  

During a bit of downtime, I finally got the courage to ask the nurse; she then pulled back his gown. His surgical wound was red, inflamed, and weeping with pus. It was packed with layers of gauze and had an odor to it. His surgical site became infected, and he became septic. Due to the sepsis, all his internal organs were shutting down. Despite the broadest and most advanced antibiotics, the damage was done, and this patient would not recover. I then realized how serious surgical site infections could be. The patient died later that day surrounded by his daughter and son.” 

Statistical Evidence 

Surgical site infections (SSIs) account for about 20% of all healthcare-associated infections (HAIs) (6). At least 5% of patients who undergo a surgical procedure develop an SSI. However, the number of SSIs are likely underestimated because about 50% of SSIs become evident after discharge (3). SSIs extend hospital stays by 9.7 days and often lead to morbidity and death. SSIs are also the most costly HAI. Increased hospitalization for an SSI can cost between $10,000 to $20,000 per admission, and up to $90,000 when the infection involves a prosthetic joint or antimicrobial-resistant infection (3).  

Despite infections control practices, such as improved sterilization methods, barriers, and surgical techniques, SSIs still persist. Antimicrobial resistance is part of the problem. In the U.S., more than 2.8 million antimicrobial-resistant infections occur each year and more than 35,000 die as a result (7). In 2019, antimicrobial resistance was associated with 5 million deaths worldwide. 

Epidemiology 

SSIs are defined as an infection that happens in a part of the body where the surgery takes place. The infection must occur at or near the incision within thirty days of the initial procedure or ninety days if there is any prosthetic material implanted during the procedure (3, 6). SSIs can be caused by either endogenous (microorganisms present on the patient’s skin when the surgical incision is made) or exogenous microorganisms (those from an outside environment). Most microorganisms that cause surgical site infections are gram-positive bacteria (such as coagulase-negative staphylococci and Staphylococcus aureus) and gram-negative counterparts (such as Escherichia coli and Pseudomonas aeruginosa) (4). Exogenous sources of microorganisms include things like operating room surfaces, contaminated surgical instruments, personnel, and the air. 

SSIs have decreased over the last several years due to a number of evidence-based interventions implemented by health care systems for prevention. Hospitals that have implemented evidence-based prevention programs have observed a 27% reduction in SSIs (1).  

Risk Factors for Surgical Site Infections 

There are three main categories for risk factors for developing surgical site infections: patient factors, wound factors, and procedural variables. 

Patient Factors 

There are several modifiable and non-modifiable patient risk factors that increase a patient’s risk of developing a surgical site infection. These include age, elevated blood sugar, tobacco use, alcoholism, steroid use, compromised immune system, infection or colonization at a remote body site, obesity, poor nutritional status, and recent radiotherapy (9, 10). We will review the most modifiable risk factors and some strategies to assist patients or providers with modification during this course. 

Tobacco Use 

Smoking is a modifiable risk factor for the development of SSIs. Smoking is associated with a significantly increased risk of SSI and additional complications of surgical procedures (8). It is recommended that smokers quit for as long as possible before and after elective surgical procedures to reduce wound complications (8). Smoking cessation is particularly important for surgical wounds with a vulnerable blood supply, such as intestinal anastomoses and tissue flaps as it causes blood flow reduction (8). Smokers have higher rates of wound healing complications and SSI. The Centers for Disease Control and Prevention offers some excellent resources to help patients quit smoking.  

Diabetes/Elevated Blood Glucose 

Elevated blood glucose levels are associated with increased risks of SSI, regardless of whether the patient has diabetes or not (3). Perioperative and postoperative glucose control is also very important and glucose during surgery and within 24 to 48 hours post-procedure should be maintained between 110 – 150 mg/dL (5). This is a new 2022 update. The prior recommendations were to keep the blood glucose below 180 mg/dL. 

 Remote Infections/Colonization 

It is important for patients with an active infection to complete treatment for that infection prior to elective surgery (5). For example, a patient has a scheduled knee replacement surgery and is undergoing treatment for impetigo (a skin infection) on their left arm. Ideally, they would complete the treatment for the impetigo prior to the knee replacement in order to avoid a possible SSI. It is particularly important to do this when there is going to be placement of prosthetic material during the procedure, like in the case of the knee replacement. 

Wound Factors 

Wound contamination is a huge risk factor for the development of an SSI. The surgical team classifies wounds based on the amount of microbial contamination, and this classification can be used as one way to assess the risk of a patient developing a surgical site infection.  

Borrowed from the Canadian Agency for Drugs and Technologies in Health (as cited in Zabaglo, 2024), the following is a classification of wounds by the amount of microbial contamination (12):  

• Class 1 (Clean): A procedure characterized by the absence of inflammation and maintenance of sterility. The gastrointestinal, urogenital, and pulmonary tracts are not accessed. 

• Class 2 (Clean-contaminated): A procedure involving entry into the gastrointestinal, urogenital, or pulmonary tracts in a controlled manner, with no existing contamination. 

• Class 3 (Contaminated): A procedure where a breach in sterile technique occurs and/or there is gross spillage from the gastrointestinal tract, or an incision through acutely inflamed (non-purulent) tissue. This category also includes open traumatic wounds that are 12 to 24 hours old. 

• Class 4 (Dirty or infected): A procedure performed on perforated viscera or an incision through acutely inflamed and purulent tissue. Open traumatic wounds older than 24 hours with necrotic tissue or fecal contamination also fall into this category. 

Risk Factors Based on Surgery Type 

The type of surgery the patient has can place them at risk for an SSI. Bucataru et al. (2024) identified the following common risk factors for SSIs based on surgical procedure type.  

Procedural Risk Factors 

There are several risk factors related to the actual procedure that can affect the risk of an SSI. The risk factors include antimicrobial prophylaxis, surgical scrub, preoperative hair removal, the protocol and choice for skin antiseptic, operating room ventilation, surgical timing, duration, and surgical techniques (5).  

The timing of surgery for a patient can lead to an increased risk of SSI. Sometimes the timing of the surgery (e.g. when during a disease course progression to have surgery versus preplanned versus emergent) can be modifiable, and sometimes, it is not (1). Patients who are undergoing emergent surgery or emergency surgery do have higher rates of SSI; this may be due to issues related to contamination or not being able to address modifiable patient risk factors (e.g., glucose control or smoking status) prior to the surgical procedure (1). Further, if a patient is undergoing treatment for cancer with chemotherapy or radiation, there is an increased risk of SSI. If an elective surgical procedure can be delayed during cancer treatment, this does decrease the risk of SSI (1).  

Classification of Surgical Site Infections 

The following is a table, borrowed from the CDC (as cited in Bucataru, et al., 2023) that classifies the type of surgical site infection, its time of onset, extent of infection, and characteristics (4). 

Infection Prevention Strategies 

There are several important infection prevention strategies to reduce the risk of SSIs. The vital pieces of SSI prevention include timely administration of preoperative antibiotics, surgical techniques, and interventions to reduce potential contamination from a healthcare worker. It is imperative to bundle these interventions for a reduction in SSI (1). 

Surgical Attire and Barrier Devices 

The American College of Surgeons has clear guidance for surgical attire (2). 

1. Surgical scrubs should not be worn for patient encounters out of the operating room (OR). 
2. OR scrubs should not be worn outside of the hospital. If worn inside of the hospital and outside of the OR, they should be covered by a clean cover or lab coat. 
3. Attire worn during a contaminated or dirty case should be changed before the next case, even if they are not visibly soiled. 
4. Any OR attire that is visibly soiled should be changed as soon as possible. 
5. During all procedures, the nose, mouth, and hair must be covered.  
6. Head and neck jewelry should be removed or covered.  
7. Double gloving is recommended to protect the surgeon. 
8. Masks, caps, gowns, drapes, and shoe covers are utilized to protect healthcare personnel from exposure to blood and body fluids. 

Hand Hygiene 

General hand hygiene practices should be followed by all surgical team members. For example, anesthesiologists and certified registered nurse anesthetists should clean their hands prior to medication administration in order to reduce microbial content on the hands. 

Healthcare personnel participating in the surgery or entering the sterile field (e.g., surgeon, scrub, or surgical assistants) must also perform surgical hand hygiene. Surgical hand hygiene consists of cleaning the hands, forearms, and under the nails with an antiseptic solution (either antiseptic soap and water or alcohol-based hand rub designed for surgical hand hygiene for at least two to five minutes (5). False fingernails, long fingernails, hand, and wrist jewelry should be removed prior to surgical hand hygiene. 

Skin Antisepsis  

It is very important to reduce microbial content or load on the skin prior to the surgical procedure which is completed by skin antisepsis (decolonization) of the patient’s skin. Skin antisepsis must be performed prior to any surgical procedure. Ideal agents for skin antisepsis should significantly reduce the bacterial load on the skin. These include an alcohol-containing preoperative skin preparatory agent in combination with an antiseptic, particularly chlorhexidine gluconate (CHG) 4% (5). For orthopedic and cardiothoracic procedures, the patient’s skin should be decolonized in the preoperative period with up to five days of intranasal mupirocin (twice daily) and bathing with CHG (daily) (5). CHG should be allowed to dry completely to achieve the maximum antiseptic effect. 

Hair Removal 

Hair removal prior to surgery should be avoided due to an increased risk of SSI. The highest risk of SSI is when surgery is performed after hair removal with a razor. Razors cause small micro-abrasions in the skin and increase the microbial load on the skin. Therefore, hair removal should not be completed with a razor. If hair removal is necessary prior to a surgical procedure, it should be done with clippers or depilatory creams as the preference due to the lowest risk of SSI (5, 11). 

Antimicrobial Prophylaxis    

Antimicrobial prophylaxis is a short course of antibiotics administered just prior to a surgical procedure to reduce the antimicrobial load in the body. Vancomycin is not recommended for surgical prophylaxis (5). Agents are chosen based on the type of surgical procedure and doses should be adjusted to the patient’s weight. For example, both oral and parenteral antibiotics are recommended as prophylaxis for colon surgeries. Additionally, povidone-iodine or CHG-based vaginal preparation agents should be used immediately before cesarean delivery to reduce the risk of endometritis (studies shown this risk is reduced by 59%) (5). Antibiotics should be discontinued at the time of incisional closure in the operating room (5).  

To recap, the following are the new 2022 updates on preventing surgical site infections in acute-care hospitals, cosigned by The Joint Commission (5). 

• Pre-operative: The use of parenteral and oral antibiotics prior to elective colorectal surgery is now an essential practice. 
• Pre-operative: Decolonization of surgical patients with an anti-staphylococcal agent for cardiothoracic and orthopedic procedures is now an essential practice. 
• Pre-operative: The use of vaginal preparation with an antiseptic solution prior to cesarean delivery and hysterectomy is now an essential practice. 
• Intra-operative: Discontinuance of antimicrobial prophylaxis should now occur at the time of incisional closure in the operating room, rather than within 24 hours after surgery. 
• Post-operative: Target blood glucose levels during the immediate postoperative period for all patients changed from <180 mg/dL to 110–150 mg/dL. 

Treatment and Management of Surgical Site Infections 

Treatment of SSIs depend on the type of surgical procedure performed, type of bacteria present in the wound, and the patient’s presentation. First and foremost, any devices in the wound (such as a mesh, implant, stent, or metalwork) may need to be removed as it can be a source of infection (12), Therefore, patients may need to return to surgery immediately. Other treatments and management strategies include obtaining wound cultures, administering antibiotics, performing assessments and wound care, and providing patient education. 

Wound Culture 

A wound culture is indicated for open wounds with suspected infection, particularly if purulent drainage is present. The nurse should obtain the wound culture and report the results to the provider (typically takes a couple of days to get the results). Wound cultures identify which bacteria is present in the wound so the appropriate antibiotic may be selected to treatment the infection (12). 

Antibiotics 

Antibiotic choice is dependent on the extent of the infection. For systemic infections, parenteral antibiotics are indicated (likely after blood cultures are obtained). Signs of an SSI that has spread systemically include fever and significant redness or cellulitis at the surgical site (12). For local infections, treatment may be limited to surgical site care.  

Wound Care 

Depending on the severity of the infection, the surgeon may open the wound incision (at the bedside), drain any purulent fluid, debride any necrotic tissue, and dress or pack the wound. If the surgeon believes the infection is deeper, the wound can be drained operatively or with the assistance of an interventional radiology team (12). Once the surgeon changes the initial postoperative dressing, the nurse may change the dressings as frequent as ordered, unless otherwise instructed.  

To promote wound healing, dressings should create a clean environment that is not too wet nor too dry (12). If the wound contains necrotic tissue and surgical debridement is not indicated, the nurse may apply debriding ointments as prescribed until the necrotic tissue is completely removed (12). The debriding ointment is enzymatic and should only be applied directly to the necrotic tissue, not the patient’s viable tissue as this can cause breakdown of healthy tissue.  

Vacuum-assisted wound therapy devices (wound VACs) may be ordered as a way to drain the wound continuously. Wound VACs use negative pressure to drain the contents of the wound so reduce the need for multiple dressing changes and prevent excess fluid accumulation caused by heavy drainage wounds. Wounds VACs have been shown successful in orthopedic, burn, open abdominal, and major trauma surgeries (12). 

Assessments 

Wound assessments are critical with each dressing change to observe for signs of worsening infection (increasing redness, warmth, tenderness, and purulent drainage). Some institutions allow use of a skin-safe marker to outline the redness around the wound, watching for spreading of the redness beyond the marked line. Nurses should follow their facility’s protocol for marking the patient’s skin. The patient’s temperature should be monitored regularly for fever. The provider may order a daily complete blood count to monitor the patient’s white blood count, particularly if the infection is systemic. The nurse should report any abnormal assessment findings to the provider.  

Patient Education 

The patient should be provided education about their condition, signs of worsening infection, and any side effects of medications used (antibiotics, ointments, or pain medications if prescribed). Any modifiable risk factors, such as smoking and obesity, should be addressed in the teaching (i.e., importance of smoking cessation and weight loss). If returning home, the patient may receive visits from a home health who can perform the dressing changes, depending on the ordered frequency. If this is not the case, the patient and/or family/caregiver should be instructed on how to perform the dressing change for when they return home. Ideally, whoever will perform the dressing change – patient, family, or caregiver – should be present during the final dressing change in the facility. They may observe the nurse perform the dressing change or change the dressing themselves with direction from the nurse.  

Conclusion 

There are many strategies to prevent and manage surgical site infections, including addressing risk factors, implementing infection prevention strategies, performing wound care, and monitoring the patient for worsening infection. The most effective programs bundle all these interventions. As the number of surgical procedures is rising, it is imperative to continue to be vigilant in preventing surgical site infections.  

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