Postoperative wound infections represent a significant challenge in surgical care, arising from a complex interplay of factors. As a common surgical complication, these infections necessitate diligent clinical attention for early identification and effective management of modifiable risk factors throughout the perioperative period. A comprehensive preoperative assessment is paramount, requiring seamless collaboration among nursing, anesthesia, and surgical teams to meticulously identify and manage patient-specific risk factors, facilitating informed patient counseling. Intraoperatively, maintaining a sterile operating room environment is non-negotiable, directly impacting patient recovery trajectories and postoperative infection rates.
While incisional infections often present with overt signs, systemic symptoms following surgery can be ambiguous, potentially mirroring conditions unrelated to surgical site infections (SSIs). These mimicking conditions, such as cellulitis, allergic reactions, urinary tract infections, and pneumonia, necessitate a robust differential diagnosis approach. Susceptibility to infection is influenced by a multitude of factors, and while diagnosis hinges primarily on clinical evaluation, wound cultures and imaging modalities may be indispensable in certain scenarios. This article provides an in-depth exploration of postoperative wound infections, encompassing etiology, epidemiology, pathophysiology, clinical presentations, evaluation strategies, and treatment modalities. Furthermore, it underscores the pivotal role of an interprofessional healthcare team and collaborative synergy between surgical and non-surgical clinicians in optimizing patient outcomes.
Objectives:
- Recognize risk factors for postoperative wound infections during preoperative evaluations.
- Implement evidence-based preventive strategies to minimize postoperative wound infection risks.
- Apply appropriate wound care techniques for the prevention and effective management of postoperative wound infections.
- Foster collaboration within interprofessional healthcare teams to ensure coordinated follow-up care and interventions, thereby enhancing patient outcomes and preventing postoperative wound infections.
Access free multiple choice questions on this topic.
Introduction
Surgical site infections (SSIs) are a leading cause of nosocomial infections in surgical patients.[1] Historically, before the germ theory revolutionized medical practice and antisepsis became standard, postoperative surgical infection rates were alarmingly high, frequently leading to severe consequences such as limb amputation or death. The advent of antiseptic techniques marked a turning point, dramatically improving patient outcomes.[2][3][4][5][6][7]
SSIs significantly contribute to postoperative morbidity and mortality. Current data indicates their responsibility for over 2 million nosocomial infections annually in the United States.[8][9][10][11] The Centers for Disease Control and Prevention (CDC) categorizes SSIs into superficial incisional, deep incisional, and organ/space infections. A surgical wound is classified as an SSI if deemed infected by the surgeon or intentionally opened due to suspected infection, occurring within 30 days post-surgery or within 1 year for procedures involving implants. For detailed SSI category definitions, refer to the CDC-National Healthcare Safety Network (NHSN) Patient Safety Component Manual, updated January 2023.
Superficial Incisional Infections
Superficial incisional SSIs are confined to the skin and subcutaneous tissues, representing over half of all SSIs. Diagnosis requires meeting at least one of the following criteria:
- Purulent drainage from the incision site.
- Isolation of a pathogenic organism from wound fluid or tissue.
- Surgeon’s clinical diagnosis of superficial incisional SSI.
- Intentional wound opening by the surgeon with at least one sign of infection (e.g., localized pain, warmth, erythema, swelling).
Deep Incisional Infections
Deep incisional SSIs involve deeper soft tissues, including muscle and fascial layers. Diagnosis requires at least one of these criteria:
- Purulent drainage from the deep incision, but not organ/space.
- Spontaneous wound dehiscence or surgical wound dehiscence opened intentionally by a surgeon when at least one of the following signs or symptoms is present: fever (>38°C), localized pain, or tenderness.
- A deep incision that is deliberately reopened by a surgeon and is culture-positive for microorganism(s).
- Evidence of deep soft tissue abscess or infection upon direct examination, during reoperation, or by histopathologic or radiologic study.
Organ/Space Infections
Organ/space SSIs affect any organ or space manipulated during surgery, excluding the incision site itself, and extend beyond the fascial/muscle layers. This includes implant-related infections. Diagnosis requires at least one of the following:
- Purulent drainage from a drain placed into the organ/space.
- Isolation of microorganisms from an aseptically obtained culture of fluid or tissue in the organ/space.
- Evidence of an abscess or infection involving the organ/space, identified via direct examination, during reoperation, or by histopathologic or radiologic study.
It is crucial to distinguish SSIs from conditions such as stitch abscesses, localized cellulitis, or infected superficial stab punctures, which are not classified as SSIs.
The majority of SSIs originate from endogenous flora, typically residing on mucous membranes, skin, or within hollow viscera. The risk of wound infection escalates significantly when microbial concentration exceeds 100,000 microorganisms per gram of tissue.[12]
Etiology
Postoperative wound infections arise from a multitude of sources, including direct contact, airborne transmission, and contamination by endogenous microbes. Patient susceptibility is modulated by a diverse array of factors. Infection patterns exhibit variability depending on the surgical procedure, operative approach, and geographical context. Risk factors are broadly categorized into patient-related and procedure-related factors.
Patient-related risk factors for wound infection encompass advanced age, malnutrition, hypovolemia, obesity, steroid use, poorly controlled diabetes mellitus, immunocompromised states, smoking, pre-existing trauma, surgical site location (intra-abdominal, pelvic, or extremity), prolonged preoperative hospitalization, inadequate preoperative skin hygiene, and distant site infections.
Optimizing modifiable patient factors prior to elective surgery is crucial. These include smoking cessation, weight management, coagulation profile normalization, glycemic control optimization, and stabilization of pre-existing comorbidities.
Procedure-related risk factors include:
- Abnormal fluid collections (hematoma, seroma)
- Surgical site, equipment, or personnel contamination
- Drain utilization
- Foreign material presence at the surgical site
- Hypothermia
- Improper hair removal techniques
- Inadequate antibiotic prophylaxis
- Insufficient skin preparation
- Inadequate preoperative surgical scrub duration
- Prolonged surgical duration
- Suboptimal operating room (OR) ventilation
- History of prior infection or contaminated surgical case
- Extended perioperative inpatient stay
- Unsatisfactory surgical practices and techniques, including:
- Failure to maintain tissue hydration through periodic saline irrigation
- Direct organ or tissue trauma
- Excessive tension during tissue traction or closure
- Excessive tissue trauma
- Failure to remove devitalized or necrotic tissue
- Inadequate hemostasis
- Leaving excessive dead space
- Overuse of electrocautery
- Tissue devascularization
- Unintended bowel content spillage
- Unnecessary or prolonged drain usage [13][14][15][16]
Adherence to preoperative and operative checklists is vital for minimizing SSI rates. The OR team shares collective responsibility for implementing best practices. Optimal OR ventilation, achieved through positive pressurization with adequate HEPA filtration, airflow, and air exchange (ideally ≥15 exchanges/hour), is paramount. Air intake should be HEPA-filtered and sourced externally, entering via ceiling or high-wall inlets, with exhausts located near floor level.[17][18]
Preoperative chlorhexidine showers, recommended the night before and/or day of surgery, aim to reduce patient skin flora. Hair removal, when necessary, should be performed immediately preoperatively using clippers (avoiding razors due to increased skin trauma risk). Clippers are generally not recommended before scrotal surgery due to potential skin trauma. Chlorhexidine and alcohol-based agents are generally favored for skin preparation in most surgical specialties.
Regular cleaning of tools and accessories (stethoscopes, blood pressure cuffs, patient transfer slides, tourniquets, computer keyboards) is crucial to prevent bacterial contamination.[19][20][21][22][23] Surgical devices (anesthesia/cautery units, suction machines, OR lighting, patient transfer aids) can also serve as contamination sources. Storage of towels, sheets, and similar materials should be within closed cabinets or outside the OR. Proper surgical scrubbing techniques and double gloving reduce postoperative infection incidence.[24] The World Health Organization (WHO) surgical safety checklist promotes communication, complication prevention, and improved safety and outcomes, including SSI prevention. Surgical procedures are classified as clean, clean-contaminated, contaminated, and dirty-infected, each associated with varying postoperative wound infection risks.
The Canadian Agency for Drugs and Technologies in Health (CADTH) Report 2011 classification defines these categories:
-
Clean: Procedures performed in the absence of inflammation, maintaining sterility without entering the gastrointestinal, urogenital, or pulmonary tracts.
-
Clean-contaminated: Procedures involving controlled entry into the gastrointestinal, urogenital, or pulmonary tracts without significant spillage or pre-existing infection.
-
Contaminated: Procedures involving a major break in sterile technique, gross spillage from the gastrointestinal tract, or incisions through acutely inflamed (non-purulent) tissue. This includes open traumatic wounds >12 to 24 hours old.
Epidemiology
Approximately 0.5% to 3% of surgical patients develop an SSI.[26] The increasing prevalence of outpatient surgery complicates postoperative data collection. The NHSN has initiated protocols to collect SSI data from ambulatory surgical centers. SSIs often manifest post-discharge or after ambulatory center visits, documented in outpatient notes potentially not integrated into hospital records. CDC/NHSN data should be interpreted within this context.
Despite enhanced preventive measures leading to a reduction in SSI incidence over time, SSIs remain a significant contributor to morbidity and mortality. They account for approximately 20% of healthcare-associated infections.[27][28] SSI patients have higher ICU admission rates and a 2 to 11 times greater mortality risk. They are also 5 times more likely to experience hospital readmission, with SSIs being the most common cause of unplanned postoperative readmissions.[29][30][31][1][32]
In 2018, the US reported 157,500 SSIs with an estimated 8205 deaths. 11% of ICU deaths were linked to SSIs. SSI patients require an average of 10-11 additional hospital days, incurring extra costs exceeding $20,000 per admission, resulting in an estimated $3.3 billion annual financial burden on the US healthcare system.[27][33]
SSI rates correlate with surgical wound contamination at the time of surgery (see Table).[34][35]
Table
Table. Surgical Site Infection Rates by Degree of Contamination.
Pathophysiology
SSI development typically begins with microbial wound contamination. Virulence and quantity of contaminating organisms are key factors, with infection often defined as >105 microorganisms per gram of tissue without a foreign body. Etiologic agents can be endogenous or exogenous. Endogenous microbes originate from the patient’s skin, mucous membranes, hollow viscera, or hematogenous spread. Common endogenous SSI pathogens vary by surgical site. Staphylococcus aureus and coagulase-negative staphylococci are frequent isolates in cardiac, breast, ophthalmic, orthopedic, and vascular surgeries. Enterococcus, gram-negative bacilli, and anaerobes are more common in abdominopelvic procedures.[36]
Exogenous microbes originate from the OR environment or personnel, transmitted via air, instruments, materials, or staff. Staphylococci and streptococci are common exogenous SSI organisms. However, highly virulent hospital-acquired organisms like methicillin-resistant S. aureus (MRSA) and extended-spectrum β-lactamase-producing microbes are increasingly isolated in SSIs, likely due to broad-spectrum antibiotic overuse. For example, a study in southeastern US community hospitals showed MRSA-associated SSI incidence increased from 12% in 2000 to 23% in 2005. The 2010 NHSN update reported 43.7% of SSIs attributed to MRSA.[12]
History and Physical Examination
SSI symptoms typically manifest 3-7 days post-procedure, but by definition, must occur within 30 or 90 days, depending on the surgical procedure type.[37]
Procedures with a 90-day SSI surveillance period include breast surgery, cardiac surgery, coronary artery bypass graft (CABG) with chest and donor site incisions, CABG with chest incision only, craniotomy, spinal fusion, open fracture reduction, herniorrhaphy, hip prosthesis, knee prosthesis, pacemaker surgery, peripheral vascular bypass surgery, and ventricular shunt placement.
Technically demanding, prolonged, contaminated, or emergent surgeries of any type increase SSI risk. Superficial or deep incisional SSI patients often present with gradual onset of surgical site pain and malaise or fatigue. They may report incisional drainage or frequently saturated dressings. Organ/space SSI patients may describe localized or generalized pain and systemic symptoms like fever, chills, night sweats, fatigue, or malaise. Physical examination may reveal incisional erythema, purulent or non-purulent discharge, wound dehiscence, or delayed healing. Tenderness to palpation may be localized or diffuse.
In-person physical examination is preferred for suspected SSIs. If impossible, visualization of the affected area is crucial. Wound photography in telemedicine has improved diagnostic accuracy and reduced overtreatment in situations where face-to-face meetings are not feasible.[38]
Dressings must be removed for examination, and the wound inspected for blisters, wound tension, edema, disproportionate tenderness, excessive erythema, fluctuance, blackish-gray tissue, and signs of ischemia or necrosis. Palpation should be performed using sterile technique. Intentional or secondary wound openings should be probed with a sterile cotton swab to assess dead space, deep closure integrity, fluid pockets, and tissue undermining. Any discharge, purulent or not, should be sampled for culture, sensitivity, and microbiological analysis.
Evaluation
SSI diagnosis is primarily clinical. However, wound cultures are essential to identify potential pathogens and guide antibiotic therapy. Imaging (ultrasound, CT, MRI) is helpful for suspected deep space infections. Risk prediction tools exist, including the National Nosocomial Infection Surveillance System, Australian Clinical Risk Index, and European System for Cardiac Operative Risk Evaluation. However, their clinical value is limited by the exclusion of many risk factors, weak discriminatory ability, or lack of surgery-specific risk stratification. Specialty- and operation-specific scoring systems are emerging, such as the Infection Risk Index in Cardiac Surgery and the Surgical Site Infection Risk Score.[39][40][41][42]
Superficial incisional SSI patients typically lack systemic infection signs, though fever and leukocytosis may be present. Imaging is generally not recommended. Deep incisional SSI patients are more likely to have systemic signs like fever. Laboratory evaluation may show leukocytosis with a left shift and elevated procalcitonin and C-reactive protein, though these are not essential for diagnosis. While superficial incisional SSI diagnosis is usually straightforward, deep incisional SSI diagnosis can be challenging clinically, especially in obese patients. Ultrasound or CT can help assess depth, extent, and anatomical involvement. Image-guided aspiration and drainage with culture can guide antibiotic therapy and improve outcomes.
Organ/space SSI patients typically present with systemic signs and symptoms of inflammation and infection, even if superficial incisions appear uninfected. Organ/space SSI diagnosis almost always requires imaging, often revealing fluid collections or abscesses near the surgical site. Image-guided aspiration is clinically useful, and interventional radiology consultation for drain placement is recommended when available.
Necrotizing soft tissue infections (NSTIs) are a distinct, life-threatening SSI subset with high morbidity and mortality. Patients typically become critically ill within 48-72 hours post-surgery and often exhibit sepsis signs. Physical examination usually reveals disproportionate pain, dusky or erythematous skin, peri-incisional edema, crepitus, ecchymosis, hypovascularity, blistering, or frank necrosis.[43][44][45] Excessive incisional drainage may be present. Laboratory evaluation may show leukocytosis or leukopenia. NSTIs can involve any tissue, spreading rapidly along fascial planes. Imaging can confirm diagnosis but should not delay surgical exploration and debridement in suspected cases.[46] Fournier gangrene is a postoperative NSTI example and a surgical emergency.[47]
Differential Diagnosis in Postoperative Wound Care
A crucial aspect of wound care, particularly in the postoperative setting, is the differential diagnosis. While the focus may be on surgical site infections, clinicians must consider other conditions that can mimic infection or complicate wound healing. A thorough differential diagnosis ensures appropriate and timely intervention, preventing misdiagnosis and suboptimal patient management.
Conditions to Consider in the Differential Diagnosis of Postoperative Wound Infections:
-
Non-Infectious Inflammatory Conditions:
- Surgical Site Inflammation: Normal postoperative inflammation can present with erythema, warmth, and mild tenderness. This is typically most pronounced in the first few days after surgery and gradually subsides. Differentiating this from infection relies on the absence of purulent drainage and systemic signs of infection.
- Seroma: A collection of serous fluid in the surgical site, seromas can cause swelling, discomfort, and sometimes erythema. They are not infections but can become secondarily infected. Aspiration can differentiate seroma fluid (clear, straw-colored) from purulent drainage.
- Hematoma: Blood collection at the surgical site can also cause swelling, bruising, and pain. Similar to seromas, hematomas are not infections but increase the risk of infection. Appearance and aspiration can aid in differentiation.
- Drug Reactions/Allergic Dermatitis: Reactions to skin preparations, dressings, sutures, or medications can manifest as erythema, pruritus, and even blistering, mimicking superficial infections. A careful history of new exposures and the distribution of the rash can be helpful.
- Contact Dermatitis: Irritation from dressings, soaps, or topical agents can cause localized inflammation. Removing the offending agent and observing for improvement can aid in diagnosis.
- Gout/Pseudogout: In patients with predisposing factors, postoperative stress can trigger crystal deposition diseases, particularly in extremity wounds. Joint involvement and crystal analysis of joint fluid (if applicable) are diagnostic.
-
Infectious Conditions Mimicking SSI:
- Cellulitis: Bacterial infection of the skin and subcutaneous tissue, cellulitis can occur near a surgical site but not be directly related to the incision. It typically presents with spreading erythema, warmth, tenderness, and often lacks a defined focus like a surgical incision.
- Erysipelas: A superficial form of cellulitis characterized by sharply demarcated, raised erythema, often caused by Streptococcus pyogenes.
- Folliculitis/Furuncles/Carbuncles: Infections of hair follicles or deeper skin structures can occur near surgical sites and be mistaken for superficial SSIs. These often present as discrete, raised, and sometimes purulent lesions rather than diffuse wound infections.
- Abscesses (Unrelated to Surgery): Pre-existing or newly developed abscesses in adjacent tissues can present with similar signs of inflammation. Location and context are important for differentiation.
- Urinary Tract Infection (UTI): Postoperative UTIs are common and can cause fever and malaise, symptoms that overlap with SSIs, especially organ/space infections if the surgery involved the urinary tract. Urinalysis is essential to rule out UTI.
- Pneumonia: Postoperative pneumonia is another common complication that can cause fever, chills, and malaise, mimicking systemic signs of infection. Respiratory symptoms and chest X-ray are key for diagnosis.
- Pulmonary Embolism (PE): While not an infection, PE can cause fever, tachycardia, and general malaise, sometimes mimicking sepsis from a severe SSI. Risk factors for PE and respiratory/cardiovascular assessments are important.
- Deep Vein Thrombosis (DVT): DVT can cause localized pain, swelling, and warmth in an extremity, potentially near a surgical site, mimicking cellulitis or deep SSI. Doppler ultrasound is used for diagnosis.
- Meningitis/Encephalitis: In neurosurgical patients, postoperative fever and altered mental status could be due to CNS infections, requiring differentiation from SSIs. Neurological exam and CSF analysis are crucial.
- Endocarditis: In patients with cardiac risk factors or procedures, endocarditis should be considered in the differential for postoperative fever, particularly if blood cultures are positive but wound cultures are negative or discordant.
Diagnostic Approach to Differential Diagnosis:
- Thorough History and Physical Examination: Detailed history including timing of symptom onset, nature of pain, presence of drainage, systemic symptoms, and relevant past medical history. Comprehensive physical exam focusing on the wound characteristics (drainage, erythema, warmth, tenderness, wound edges, depth), and assessment for systemic signs (fever, tachycardia, hypotension).
- Wound Assessment: Careful inspection of the wound, noting the type of drainage (purulent, serous, serosanguineous), color, odor, and extent of surrounding erythema and induration. Palpation to assess for fluctuance, warmth, and tenderness.
- Wound Culture: Collect wound cultures, particularly if drainage is present, to identify causative organisms and guide antibiotic therapy if infection is suspected.
- Laboratory Investigations:
- Complete Blood Count (CBC): Leukocytosis with neutrophilia may suggest infection, but can also be elevated due to non-infectious inflammation.
- C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): Elevated inflammatory markers, but non-specific and can be elevated in both infectious and non-infectious conditions.
- Urinalysis: To rule out UTI, particularly if urinary symptoms are present or the surgery involved the urinary tract.
- Blood Cultures: Consider if systemic signs of infection are present, especially in suspected sepsis or organ/space infections.
- Imaging Studies:
- Ultrasound: Useful for identifying fluid collections (seroma, hematoma, abscess) and guiding aspiration.
- CT Scan/MRI: For deeper infections or organ/space infections, to delineate the extent of infection and identify abscesses. Also helpful in ruling out other intra-abdominal or thoracic conditions.
- Chest X-ray: To rule out pneumonia, especially if respiratory symptoms are present.
- Doppler Ultrasound: To rule out DVT if extremity swelling or pain is present.
- Aspiration and Fluid Analysis: Aspirate fluid collections (seroma, hematoma, suspected abscesses) for Gram stain, culture, and cell count to differentiate infectious from non-infectious collections.
- Clinical Course and Response to Treatment: Monitor the patient’s clinical course and response to interventions. Lack of improvement with antibiotics may suggest a non-infectious etiology or antibiotic resistance. Conversely, resolution with wound care and/or antibiotics supports the diagnosis of SSI.
A systematic approach to differential diagnosis, incorporating clinical assessment, laboratory and imaging investigations, and consideration of alternative diagnoses, is essential for effective postoperative wound care and preventing misdiagnosis of surgical site infections.
Treatment / Management
Preventive Measures
Preventive measures are paramount to minimize postoperative infections. A checklist-based approach and meticulous attention to known risk factors are crucial. The “CDC and Health Infection Control Practice Advisory Committee Guideline for the Prevention of Surgical Site Infections” (2017) provides comprehensive, evidence-based recommendations. Preventive measures are categorized into pre-procedural, perioperative, and intraoperative phases. Pre-procedural considerations include optimizing chronic health conditions (glucose control), medication review, addressing chronic wounds/infections, and smoking cessation. Perioperative steps encompass preoperative showers, hair clipping, operation-specific antibiotic administration, and appropriate skin preparation. Maintaining optimal intraoperative conditions (temperature, air circulation, sterility) is vital for preventing wound infections.[29][48]
A large Japanese study demonstrated significant SSI reduction through perioperative oral hygiene regimens, including tartar/plaque/scale removal, professional dental cleaning, optimal denture care/adjustments, and high-quality general dental care (extractions as needed preoperatively).[49] A large trial showed that changing surgical gloves and instruments immediately before abdominal wound closure resulted in a statistically significant SSI rate reduction. While preliminary, these findings warrant further research to validate this approach.[50]
Routine surgical drain use is discouraged due to uncertain efficacy in SSI prevention and potential impedance of early patient mobilization.[51][52][53] If used, drains should be promptly removed. Various measures (antibiotic irrigation, topical antimicrobial gels, antibiotic-impregnated sutures, antiseptic dressings) have been explored to reduce SSI incidence, but definitive evidence of significant efficacy is currently lacking.
Delayed primary closure, historically used for significantly contaminated wounds, aimed to reduce SSIs in specific populations. However, a meta-analysis of randomized studies showed no significant clinical benefit with this practice.[54][55] Antibiotic selection, tailored to the surgical procedure and prevalent microbes, remains crucial for SSI prevention.
Prophylactic negative pressure wound therapy (NPWT) for closed surgical incisions has been proposed for high-risk and contaminated wounds.[56][57] Data generally support NPWT in high-risk surgeries, but outcomes vary, likely due to differences in wound contamination levels and patient/wound characteristics.[58][59] Evidence does not suggest that surgical dressing selection for closed incisions significantly impacts SSI incidence.[60] However, prophylactic wound protectors for laparoscopy, laparotomy, and orthopedic incisions appear beneficial.[61][62][63][64][65][66]
Treatment of Surgical Site Infections
Treatment decisions depend on the procedure, microbes involved, anatomical considerations, and patient characteristics. Foreign body presence (mesh, implants, stents, metalwork) may necessitate removal due to contamination and biofilm formation.[67] Cultures are indicated for open wounds and drainage, especially purulent, to guide antibiotic selection. Negative wound cultures may suggest unusual infections (acid-fast bacteria, fungi), particularly in immunocompromised patients, requiring specific cultures.
Systemic antibiotics are needed for systemic infection signs (fever, significant erythema, cellulitis) or deeper soft tissue involvement. Blood cultures should be considered in patients with systemic infection signs. Timely interventions in sepsis are life-saving. Superficial infections may be treated with local wound care.[68] Superficial wound infection treatment involves incision opening, wound examination, infected fluid drainage, and necrotic tissue debridement, typically at the bedside or in the office. Deeper involvement may require drainage via interventional radiology or in the OR.
Opened wounds require dressings to create a clean, moisture-balanced environment, with appropriate debridement and temperature maintenance to promote healing.[69] A balanced wound matrix prevents desiccation-induced necrosis and contains growth factors supporting healing, epithelial regeneration, and autolysis of dead tissue. Wound dressings are tailored to specific wound environments. Dressing choice and change frequency depend on wound condition and healing stage. Topical antiseptics (hydrogen peroxide, dilute sodium hypochlorite, povidone-iodine) may be sparingly used in infected open wounds, but application should be limited due to cytotoxicity to the wound matrix.
Enzymatic agents are used when mechanical debridement is not feasible.[70] Cleaning and debridement should be repeated until necrotic/devitalized tissue is absent and healthy granulation tissue forms. Infected foreign material/implants should be removed.
Vacuum-assisted wound therapy (NPWT) uses negative pressure to minimize dressing changes, avoid fluid accumulation, and promote granulation. NPWT is used for major trauma, orthopedic procedures, burn surgeries, and open abdominal wounds.[71] Meta-analyses show statistically significant SSI reduction after spinal surgery, fewer postoperative complications, and shorter hospital stays with NPWT.[[72]](#article-31404.r72] Similar positive outcomes with NPWT (VAC) have been reported for SSIs after cesarean sections.[73]
NPWT-managed wounds may require intermittent mechanical debridement. NPWT requires specialized oversight, especially with exposed underlying organs or major blood vessels. Deep abdominal SSIs pose unique challenges due to dehiscence risk. Exploration may be safer in the OR. Percutaneous drainage may be considered for infected fluid collections. Organ/space SSIs have higher morbidity and mortality. Ultrasound/CT-guided percutaneous drain placement into infected fluid collections/abscesses, potentially related to anastomotic leaks after bowel surgery, is helpful. Air or contrast in an intra-abdominal abscess suggests bowel perforation or anastomotic leak.
Special Situations
Mesh-related infections (hernias) typically require drainage (percutaneous possible), antibiotics, wound debridement, and potential mesh removal. If no improvement in 10-14 days, more aggressive intervention (OR exploration, mesh removal) may be needed. While some reports describe successful treatment with systemic and locally injected antibiotics, this is not standard care and generally not recommended.[74][75][76]
Orthopedic hardware infection management may include bone debridement, antibiotic wound therapy, long-term antibiotics, implant/cement removal, wound irrigation, and/or surgical debridement.[77] Select patients may be treated with debridement and antibiotics without hardware removal, but failure likely requires resection arthroplasty.[78][79] Antibiotic-impregnated cement/polymer-coated intramedullary nails show promise in preliminary studies.[80] Infected vascular grafts generally require affected section removal and alternative vascular augmentation using uninfected tissue.[81][82] Compromised overlying skin may need excision.[83] Partial graft excision may be reasonable in selected patients, but meta-analyses show high recurrent infection risk and reoperation necessity.[84]
Absorbable meshes, providing structural matrix and releasing healing/tissue growth factors, are promising adjunct treatments for impaired wound healing, especially in diabetic patients.[85] Hyperbaric oxygen therapy may be used for complex, non-healing postoperative wounds, with reported ~75% success rates. See StatPearls’ “Hyperbaric Therapy for Wound Healing” for more information.”[86]
Prognosis
Early recognition and prompt treatment of surgical wounds are crucial for optimal prognosis. Prevention protocol adherence is the most prudent approach. Various models aid in identifying high-risk patients and preventing SSIs. For example, a colorectal cancer study identified physiological factors, tumor characteristics, and surgery type as SSI predictors.[87] Surgical factors (procedure type, emergency surgery, wound class, drains, surgeon experience, prolonged OR time) and postoperative factors (extended hospital stay, intraoperative transfusions) are independent SSI risk factors.[88]
Complications
SSI complications can be local or systemic. Local complications include delayed wound healing, chronic wounds, local tissue damage, superimposed infections, abscess formation, and osteomyelitis. Systemic complications include bacteremia, hematogenous spread, sepsis, organ failure, and exacerbation of comorbidities.
Postoperative and Rehabilitation Care
Postoperative wound care is central to postoperative hospital/rehabilitation stays, as the wound may be the primary reason for in-house care. Effective wound care and healing are essential for patient well-being and survival. Wound care is an evolving, sophisticated specialty. Adequate postoperative wound care requires timely evaluation and deliberate interventions for optimal patient outcomes.
Consultations
Postoperative wound infection management may require expertise from infectious disease, plastic surgery, and critical care specialists.
Deterrence and Patient Education
Modifiable patient risk factors (BMI, diabetic control, smoking status) can minimize postoperative wound infections. Elective surgeries involve preoperative education and counseling. Patients may be encouraged to lose weight, adhere to medication regimens, and adopt healthy habits preoperatively. Smoking cessation is crucial. Family involvement in these discussions is beneficial. Recommendations and protocols vary based on preexisting conditions and planned surgery. Spinal surgery protocols may suggest HbA1c <8%, α-blockers for males ≥60, serum albumin >3.5 g/dL, cardiac stress tests, and smoking cessation.[89]
Pearls and Other Issues
Antiseptic Preoperative Prep Solutions
Iodine-based sterilizing solutions (povidone-iodine) release free iodine, disrupting bacterial DNA and essential intracellular proteins. They are broad-spectrum, accessible, cost-effective, and safe for all skin surfaces, especially beneficial for transvaginal/transurethral prep due to mucosal surface safety. Caution is needed in iodine allergy, and these solutions should be avoided in such patients. Typically, skin is scrubbed and then painted with iodine solution.
Alcohol-based prep solutions are broad-spectrum, inexpensive, fast, and quick-acting. Single application is usually sufficient, and they dry rapidly. Compared to iodine-based solutions, they are easier to apply, have longer-lasting antimicrobial effect, greater efficacy, shorter drying times, and are more cost-effective. However, they are flammable, requiring complete skin drying before proceeding, and are unsuitable for mucous membranes.[1]
Chlorhexidine gluconate (aqueous solution) disrupts bacterial cell membranes, offering longer antiseptic activity than iodine-based antiseptics and is more resistant to neutralization. Chlorhexidine is common for preoperative showering, surgeon hand-scrubbing, and skin prep. A large study comparing chlorhexidine to iodine-based skin prep showed no significant SSI rate difference.[90]
Alcohol-based solutions with iodine or chlorhexidine combine benefits, generally providing longer-duration antisepsis than single agents. Combining agents with different antimicrobial modes appears to provide additive efficacy compared to single agents.[91]
Surgical prophylaxis antibiotic selection should be safe, narrow-spectrum, and cover expected microorganisms. Administer antibiotics 30-60 minutes before incision/instrumentation to ensure therapeutic levels by surgery start.
- Clean procedures: Antibiotics should cover skin flora, primarily staphylococci.
- Clean-contaminated procedures: Coverage should extend to gram-negative rods and enterococci, alongside staphylococci, depending on procedure. Common choices: cefazolin 2 g (weight-adjusted) or vancomycin 15 mg/kg + metronidazole, cefoxitin, or ertapenem.
- Contaminated and dirty procedures: Continue pre-established antibiotic regimen or adjust intraoperatively based on findings.*
*Note: Infectious disease and pharmacy professionals should be involved to optimize treatment based on perioperative culture results.
Enhancing Healthcare Team Outcomes
Perioperatively, patients interact with numerous healthcare professionals involved in mitigating SSI risk. Preoperatively, identify and address modifiable risk factors and provide patient counseling on potential risks. While risk discussions are primarily by nursing staff, anesthesiologists, and surgeons, all interprofessional team members must educate patients and reinforce preventive measures.
Maintaining OR cleanliness, especially around the operating table, is essential. Items like anesthesia units, personal staff belongings, and medical equipment should be considered contaminated and cleaned regularly. Intraoperatively, OR personnel must maintain sterility and optimize the surgical environment. Postoperatively, all involved clinicians influence recovery and SSI rates.[92]
Review Questions
References
1.Hemani ML, Lepor H. Skin preparation for the prevention of surgical site infection: which agent is best? Rev Urol. 2009 Fall;11(4):190-5. [PMC free article: PMC2809986] [PubMed: 20111631]
2.O’donnell KF. Wisdom from Ignaz Semmelweis. Nursing. 2021 Oct 01;51(10):69-70. [PubMed: 34580267]
3.Cavaillon JM, Chrétien F. From septicemia to sepsis 3.0 – from Ignaz Semmelweis to Louis Pasteur. Microbes Infect. 2019 Jun-Jul;21(5-6):213-221. [PubMed: 31255674]
4.Absolon KB, Absolon MJ, Zientek R. From antisepsis to asepsis. Louis Pasteur’s publication on “The germ theory and its application to medicine and surgery”. Rev Surg. 1970 Jul-Aug;27(4):245-58. [PubMed: 4918488]
5.Nakayama DK. Antisepsis and Asepsis and How They Shaped Modern Surgery. Am Surg. 2018 Jun 01;84(6):766-771. [PubMed: 29981599]
6.Michaleas SN, Laios K, Charalabopoulos A, Samonis G, Karamanou M. Joseph Lister (1827-1912): A Pioneer of Antiseptic Surgery. Cureus. 2022 Dec;14(12):e32777. [PMC free article: PMC9854334] [PubMed: 36686094]
7.Toledo-Pereyra LH, Toledo MM. A critical study of Lister’s work on antiseptic surgery. Am J Surg. 1976 Jun;131(6):736-44. [PubMed: 779507]
8.Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol. 2002 Apr;23(4):183-9. [PubMed: 12002232]
9.Perencevich EN, Sands KE, Cosgrove SE, Guadagnoli E, Meara E, Platt R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis. 2003 Feb;9(2):196-203. [PMC free article: PMC2901944] [PubMed: 12603990]
10.Anderson DJ, Kaye KS, Chen LF, Schmader KE, Choi Y, Sloane R, Sexton DJ. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009 Dec 15;4(12):e8305. [PMC free article: PMC2788700] [PubMed: 20016850]
11.Rahman MS, Hasan K, Ul Banna H, Raza AM, Habibullah T. A study on initial outcome of selective non-operative management in penetrating abdominal injury in a tertiary care hospital in Bangladesh. Turk J Surg. 2019 Jun;35(2):117-123. [PMC free article: PMC6796071] [PubMed: 32550316]
12.Young PY, Khadaroo RG. Surgical site infections. Surg Clin North Am. 2014 Dec;94(6):1245-64. [PubMed: 25440122]
13.Consensus paper on the surveillance of surgical wound infections. The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Infect Control Hosp Epidemiol. 1992 Oct;13(10):599-605. [PubMed: 1334987]
14.Vitiello R, Perna A, Peruzzi M, Pitocco D, Marco G. Clinical evaluation of tibiocalcaneal arthrodesis with retrograde intramedullary nail fixation in diabetic patients. Acta Orthop Traumatol Turc. 2020 May;54(3):255-261. [PMC free article: PMC7586767] [PubMed: 32544061]
15.Albertini R, Coluccia A, Colucci ME, Zoni R, Affanni P, Veronesi L, Pasquarella C. An overview of the studies on microbial air contamination in operating theatres and related issues over time: a useful tool for a multidisciplinary approach. Acta Biomed. 2023 Aug 30;94(S3):e2023149. [PubMed: 37695181]
16.Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, Nyquist AC, Saiman L, Yokoe DS, Maragakis LL, Kaye KS. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jun;35(6):605-27. [PMC free article: PMC4267723] [PubMed: 24799638]
17.Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 279-80. [PubMed: 10219875]
18.Macefield RC, Reeves BC, Milne TK, Nicholson A, Blencowe NS, Calvert M, Avery KN, Messenger DE, Bamford R, Pinkney TD, Blazeby JM. Development of a single, practical measure of surgical site infection (SSI) for patient report or observer completion. J Infect Prev. 2017 Jul;18(4):170-179. [PMC free article: PMC5495441] [PubMed: 28989524]
19.Fellowes C, Kerstein R, Clark J, Azadian BS. MRSA on tourniquets and keyboards. J Hosp Infect. 2006 Sep;64(1):86-8. [PubMed: 16824648]
20.Messina G, Ceriale E, Lenzi D, Burgassi S, Azzolini E, Manzi P. Environmental contaminants in hospital settings and progress in disinfecting techniques. Biomed Res Int. 2013;2013:429780. [PMC free article: PMC3830765] [PubMed: 24286078]
21.De Groote P, Blot K, Conoscenti E, Labeau S, Blot S. Mobile phones as a vector for Healthcare-Associated Infection: A systematic review. Intensive Crit Care Nurs. 2022 Oct;72:103266. [PubMed: 35688751]
22.Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial contamination of keyboards: efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol. 2006 Apr;27(4):372-7. [PubMed: 16622815]
23.Brady RR, Fraser SF, Dunlop MG, Paterson-Brown S, Gibb AP. Bacterial contamination of mobile communication devices in the operative environment. J Hosp Infect. 2007 Aug;66(4):397-8. [PubMed: 17573157]
24.Spagnolo AM, Ottria G, Amicizia D, Perdelli F, Cristina ML. Operating theatre quality and prevention of surgical site infections. J Prev Med Hyg. 2013 Sep;54(3):131-7. [PMC free article: PMC4718372] [PubMed: 24783890]
25.Kamel C, McGahan L, Mierzwinski-Urban M, Embil J. Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections [Internet]. Canadian Agency for Drugs and Technologies in Health; Ottawa (ON): Jun, 2011. [PubMed: 24354038]
26.Seidelman JL, Mantyh CR, Anderson DJ. Surgical Site Infection Prevention: A Review. JAMA. 2023 Jan 17;329(3):244-252. [PubMed: 36648463]
27.Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Itani KM, Dellinger EP, Ko CY, Duane TM. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017 Jan;224(1):59-74. [PubMed: 27915053]
28.Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surg Infect (Larchmt). 2012 Aug;13(4):234-7. [PubMed: 22913334]
29.Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP., Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 01;152(8):784-791. [PubMed: 28467526]
30.Lewis SS, Moehring RW, Chen LF, Sexton DJ, Anderson DJ. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol. 2013 Nov;34(11):1229-30. [PMC free article: PMC3977691] [PubMed: 24113613]
31.Merkow RP, Ju MH, Chung JW, Hall BL, Cohen ME, Williams MV, Tsai TC, Ko CY, Bilimoria KY. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015 Feb 03;313(5):483-95. [PubMed: 25647204]
32.Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999 Nov;20(11):725-30. [PubMed: 10580621]
33.Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46. [PubMed: 23999949]
34.Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med. 1991 Sep 16;91(3B):152S-157S. [PubMed: 1656747]
35.López Pereira P, Díaz-Agero Pérez C, López Fresneña N, Las Heras Mosteiro J, Palancar Cabrera A, Rincón Carlavilla ÁL, Aranaz Andrés JM. ‘Epidemiology of surgical site infection in a neurosurgery department’. Br J Neurosurg. 2017 Feb;31(1):10-15. [PubMed: 27905216]
36.Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008 Nov;70 Suppl 2:3-10. [PubMed: 19022115]
37.Russo V, Leaptrot D, Otis M, Smith H, Hebden JN, Wright MO. Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network Data Quality Collaboration Case Study – Chapter 9 Surgical site infection event (SSI) case study. Am J Infect Control. 2022 Jul;50(7):799-800. [PubMed: 35417770]
38.Sanger PC, Simianu VV, Gaskill CE, Armstrong CA, Hartzler AL, Lordon RJ, Lober WB, Evans HL. Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study. J Am Coll Surg. 2017 Jan;224(1):8-15.e1. [PMC free article: PMC5183503] [PubMed: 27746223]
39.van Walraven C, Musselman R. The Surgical Site Infection Risk Score (SSIRS): A Model to Predict the Risk of Surgical Site Infections. PLoS One. 2013;8(6):e67167. [PMC free article: PMC3694979] [PubMed: 23826224]
40.Bustamante-Munguira J, Herrera-Gómez F, Ruiz-Álvarez M, Figuerola-Tejerina A, Hernández-Aceituno A. A New Surgical Site Infection Risk Score: Infection Risk Index in Cardiac Surgery. J Clin Med. 2019 Apr 09;8(4) [PMC free article: PMC6517895] [PubMed: 30970636]
41.Emori TG, Culver DH, Horan TC, Jarvis WR, White JW, Olson DR, Banerjee S, Edwards JR, Martone WJ, Gaynes RP. National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control. 1991 Feb;19(1):19-35. [PubMed: 1850582]
42.Figuerola-Tejerina A, Bustamante E, Tamayo E, Mestres CA, Bustamante-Munguira J. Ability to predict the development of surgical site infection in cardiac surgery using the Australian Clinical Risk Index versus the National Nosocomial Infections Surveillance-derived Risk Index. Eur J Clin Microbiol Infect Dis. 2017 Jun;36(6):1041-1046. [PubMed: 28105547]
43.Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 07;377(23):2253-2265. [PubMed: 29211672]
44.Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15;59(2):147-59. [PubMed: 24947530]
45.Hua C, Urbina T, Bosc R, Parks T, Sriskandan S, de Prost N, Chosidow O. Necrotising soft-tissue infections. Lancet Infect Dis. 2023 Mar;23(3):e81-e94. [PubMed: 36252579]
46.Leslie SW, Rad J, Foreman J. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 5, 2023. Fournier Gangrene. [PubMed: 31747228]
47.Nagle SM, Stevens KA, Wilbraham SC. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 26, 2023. Wound Assessment. [PubMed: 29489199]
48.Walker J. Reducing the risk of surgical site infections. Nurs Stand. 2023 Oct 04;38(10):77-81. [PubMed: 37691566]
49.Shimane T, Koike K, Fujita S, Kurita H, Isomura ET, Chikazu D, Kanno N, Sasaki K, Hino S, Hibi H, Koyama T, Nakamura S, Nomura T, Mori Y, Tojyo I, Yamamoto T, Yamamori I, Aota K, Tanzawa H. Positive impact of perioperative oral management on the risk of surgical site infections after abdominal surgery: Sixteen universities in Japan. Medicine (Baltimore). 2023 Sep 15;102(37):e35066. [PMC free article: PMC10508462] [PubMed: 37713859]
50.Ferreira J, Joos E, Bhandari M, Dixon E, Brown CJ., Evidence-Based Reviews in Surgery Group. Routine Sterile Glove and Instrument Change at the Time of Abdominal Wound Closure to Prevent Surgical Site Infection: Reviewing the ChEETAh Trial. J Am Coll Surg. 2024 Jan 01;238(1):139-143. [PubMed: 37721383]
51.Muthu S, Ramakrishnan E, Natarajan KK, Chellamuthu G. Risk-benefit analysis of wound drain usage in spine surgery: a systematic review and meta-analysis with evidence summary. Eur Spine J. 2020 Sep;29(9):2111-2128. [PubMed: 32700123]
52.Yang J, Liu Y, Yan P, Tian H, Jing W, Si M, Yang K, Guo T. Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis. Medicine (Baltimore). 2020 May;99(20):e20070. [PMC free article: PMC7253658] [PubMed: 32443316]
53.Holubar SD, Hedrick T, Gupta R, Kellum J, Hamilton M, Gan TJ, Mythen MG, Shaw AD, Miller TE., Perioperative Quality Initiative (POQI) I Workgroup. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery. Perioper Med (Lond). 2017;6:4. [PMC free article: PMC5335800] [PubMed: 28270910]
54.Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA Surg. 2013 Aug;148(8):779-86. [PubMed: 23803860]
55.He JC, Zosa BM, Schechtman D, Brajcich B, Savakus JC, Wojahn AL, Wang DZ, Claridge JA. Leaving the Skin Incision Open May Not Be as Beneficial as We Have Been Taught. Surg Infect (Larchmt). 2017 May/Jun;18(4):431-439. [PubMed: 28332921]
56.Wang C, Zhang Y, Qu H. Negative pressure wound therapy for closed incisions in orthopedic trauma surgery: a meta-analysis. J Orthop Surg Res. 2019 Dec 11;14(1):427. [PMC free article: PMC6907184] [PubMed: 31829217]
57.Gombert A, Dillavou E, D’Agostino R, Griffin L, Robertson JM, Eells M. A systematic review and meta-analysis of randomized controlled trials for the reduction of surgical site infection in closed incision management versus standard of care dressings over closed vascular groin incisions. Vascular. 2020 Jun;28(3):274-284. [PMC free article: PMC7294533] [PubMed: 31955666]
58.Kuper TM, Murphy PB, Kaur B, Ott MC. Prophylactic Negative Pressure Wound Therapy for Closed Laparotomy Incisions: A Meta-analysis of Randomized Controlled Trials. Ann Surg. 2020 Jan;271(1):67-74. [PubMed: 31860549]
59.Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi WJ, Karanicolas PJ. The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: A systematic review and meta-analysis. Surgery. 2020 Jun;167(6):1001-1009. [PubMed: 32143842]
60.Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, Blencowe N, Milne TK, Reeves BC, Blazeby J. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016 Dec 20;12(12):CD003091. [PMC free article: PMC6464019] [PubMed: 27996083]
61.Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG. Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg. 2012 Jul;256(1):53-9. [PubMed: 22584694]
62.Liu JB, Baker MS, Thompson VM, Kilbane EM, Pitt HA. Wound protectors mitigate superficial surgical site infections after pancreatoduodenectomy. HPB (Oxford). 2019 Jan;21(1):121-131. [PubMed: 30077524]
63.Kobayashi H, Uetake H, Yasuno M, Sugihara K. Effectiveness of Wound-Edge Protectors for Preventing Surgical Site Infections after Open Surgery for Colorectal Disease: A Prospective Cohort Study with Two Parallel Study Groups. Dig Surg. 2019;36(1):83-88. [PubMed: 29698971]
64.Bressan AK, Roberts DJ, Edwards JP, Bhatti SU, Dixon E, Sutherland FR, Bathe O, Ball CG. Efficacy of a dual-ring wound protector for prevention of incisional surgical site infection after Whipple’s procedure (pancreaticoduodenectomy) with preoperatively-placed intrabiliary stents: protocol for a randomised controlled trial. BMJ Open. 2014 Aug 21;4(8):e005577. [PMC free article: PMC4156806] [PubMed: 25146716]
65.Luo Y, Qiu YE, Mu YF, Qin SL, Qi Y, Zhong M, Yu MH, Ma LY. Plastic wound protectors decreased surgical site infections following laparoscopic-assisted colectomy for colorectal cancer: A retrospective cohort study. Medicine (Baltimore). 2017 Sep;96(37):e7752. [PMC free article: PMC5604629] [PubMed: 28906360]
66.Mihaljevic AL, Schirren R, Özer M, Ottl S, Grün S, Michalski CW, Erkan M, Jäger C, Reiser-Erkan C, Kehl V, Schuster T, Roder J, Clauer U, Orlitsch C, Hoffmann TF, Lange R, Harzenetter T, Steiner P, Michalski M, Henkel K, Stadler J, Pistorius GA, Jahn A, Obermaier R, Unger R, Strunk R, Willeke F, Vogelsang H, Halve B, Dietl KH, Hilgenstock H, Meyer A, Krämling HJ, Wagner M, Schoenberg MH, Zeller F, Schmidt J, Friess H, Kleeff J. Multicenter double-blinded randomized controlled trial of standard abdominal wound edge protection with surgical dressings versus coverage with a sterile circular polyethylene drape for prevention of surgical site infections: a CHIR-Net trial (BaFO; NCT01181206). Ann Surg. 2014 Nov;260(5):730-7; discussion 737-9. [PubMed: 25379844]
67.Lall RR, Wong AP, Lall RR, Lawton CD, Smith ZA, Dahdaleh NS. Evidence-based management of deep wound infection after spinal instrumentation. J Clin Neurosci. 2015 Feb;22(2):238-42. [PubMed: 25308619]
68.Yin D, Liu B, Chang Y, Gu H, Zheng X. Management of late-onset deep surgical site infection after instrumented spinal surgery. BMC Surg. 2018 Dec 22;18(1):121. [PMC free article: PMC6303994] [PubMed: 30577832]
69.Ovington LG. Hanging wet-to-dry dressings out to dry. Home Healthc Nurse. 2001 Aug;19(8):477-83; quiz 484. [PubMed: 11982183]
70.Steed DL. Debridement. Am J Surg. 2004 May;187(5A):71S-74S. [PubMed: 15147995]
71.Ding J, Zhu Y, Ge H, Chen H, Wang L, Xie S, Zhang S, Deng Y, Yang R, Guo H. Negative Pressure Wound Therapy for Patients With Complicated Mucocutaneous Separation Following Ileal Conduit Urinary Diversion: A Case Series. 2023 Sep-Oct 01J Wound Ostomy Continence Nurs. 50(5):420-426. [PubMed: 37713355]
72.Lu S, Yuan Z, He X, Du Z, Wang Y. The impact of negative pressure wound therapy on surgical wound infection, hospital stay and postoperative complications after spinal surgery: A meta-analysis. Int Wound J. 2024 Jan;21(1):e14378. [PMC free article: PMC10784618] [PubMed: 37697710]
73.Zhu Y, Dai L, Luo B, Zhang L. Meta-analysis of prophylactic negative pressure wound therapy for surgical site infections (SSI) in caesarean section surgery. Wideochir Inne Tech Maloinwazyjne. 2023 Jun;18(2):224-234. [PMC free article: PMC10481433] [PubMed: 37680737]
74.Alston D, Parnell S, Hoonjan B, Sebastian A, Howard A. Conservative management of an infected laparoscopic hernia mesh: A case study. Int J Surg Case Rep. 2013;4(11):1035-7. [PMC free article: PMC3825931] [PubMed: 24099982]
75.Aguilar B, Chapital AB, Madura JA, Harold KL. Conservative management of mesh-site infection in hernia repair. J Laparoendosc Adv Surg Tech A. 2010 Apr;20(3):249-52. [PubMed: 20156120]
76.Trunzo JA, Ponsky JL, Jin J, Williams CP, Rosen MJ. A novel approach for salvaging infected prosthetic mesh after ventral hernia repair. Hernia. 2009 Oct;13(5):545-9. [PubMed: 19214650]
77.Trebse R, Pisot V, Trampuz A. Treatment of infected retained implants. J Bone Joint Surg Br. 2005 Feb;87(2):249-56. [PubMed: 15736752]
78.Geurts JA, Janssen DM, Kessels AG, Walenkamp GH. Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta Orthop. 2013 Dec;84(6):509-16. [PMC free article: PMC3851662] [PubMed: 24171687]
79.Van Kleunen JP, Knox D, Garino JP, Lee GC. Irrigation and débridement and prosthesis retention for treating acute periprosthetic infections. Clin Orthop Relat Res. 2010 Aug;468(8):2024-8. [PMC free article: PMC2895859] [PubMed: 20224960]
80.Solanki T, Maurya MK, Singh PK. Results of Antibiotic-Impregnated Cement/Polymer-Coated Intramedullary Nails in the Management of Infected Nonunion and Open Fractures of Long Bones. Cureus. 2023 Aug;15(8):e43421. [PMC free article: PMC10496935] [PubMed: 37706117]
81.Bosman PJ, Blankestijn PJ, van der Graaf Y, Heintjes RJ, Koomans HA, Eikelboom BC. A comparison between PTFE and denatured homologous vein grafts for haemodialysis access: a prospective randomised multicentre trial. The SMASH Study Group. Study of Graft Materials in Access for Haemodialysis. Eur J Vasc Endovasc Surg. 1998 Aug;16(2):126-32. [PubMed: 9728431]
82.Benrashid E, Youngwirth LM, Mureebe L, Lawson JH. Operative and perioperative management of infected arteriovenous grafts. J Vasc Access. 2017 Jan 18;18(1):13-21. [PubMed: 27834454]
83.McKenna PJ, Leadbetter MG. Salvage of chronically exposed Gore-Tex vascular access grafts in the hemodialysis patient. Plast Reconstr Surg. 1988 Dec;82(6):1046-51. [PubMed: 3200941]
84.Tullavardhana T, Chartkitchareon A. Meta-analysis of total versus partial graft excision: Which is the better choice to manage arteriovenous dialysis graft infection? Ann Saudi Med. 2022 Sep-Oct;42(5):343-350. [PMC free article: PMC9557782] [PubMed: 36252149]
85.Vasalou V, Kotidis E, Tatsis D, Boulogeorgou K, Grivas I, Koliakos G, Cheva A, Ioannidis O, Tsingotjidou A, Angelopoulos S. The Effects of Tissue Healing Factors in Wound Repair Involving Absorbable Meshes: A Narrative Review. J Clin Med. 2023 Aug 31;12(17) [PMC free article: PMC10488606] [PubMed: 37685753]
86.Jones MW, Cooper JS. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 12, 2023. Hyperbaric Therapy for Wound Healing. [PubMed: 29083562]
87.Sagawa M, Yokomizo H, Yoshimatsu K, Yano Y, Okayama S, Sakuma A, Satake M, Yamada Y, Usui T, Yamaguchi K, Shiozawa S, Shimakawa T, Katsube T, Kato H, Naritaka Y. [Relationship between Surgical Site Infection(SSI)Incidence and Prognosis in Colorectal Cancer Surgery]. Gan To Kagaku Ryoho. 2017 Oct;44(10):921-923. [PubMed: 29066696]
88.Isik O, Kaya E, Dundar HZ, Sarkut P. Surgical Site Infection: Re-assessment of the Risk Factors. Chirurgia (Bucur). 2015 Sep-Oct;110(5):457-61. [PubMed: 26531790]
89.Epstein NE. Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery. Surg Neurol Int. 2018;9:251. [PMC free article: PMC6302553] [PubMed: 30637169]
90.Ghobrial GM, Wang MY, Green BA, Levene HB, Manzano G, Vanni S, Starke RM, Jimsheleishvili G, Crandall KM, Dididze M, Levi AD. Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients. J Neurosurg Spine. 2018 Feb;28(2):209-214. [PubMed: 29171793]
91.Hibbard JS. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs. 2005 May-Jun;28(3):194-207. [PubMed: 15912075]
92.Anderson PA, Savage JW, Vaccaro AR, Radcliff K, Arnold PM, Lawrence BD, Shamji MF. Prevention of Surgical Site Infection in Spine Surgery. Neurosurgery. 2017 Mar 01;80(3S):S114-S123. [PubMed: 28350942]