Healthcare-Associated Infections _ ______________________________________________________________
DISTRIBUTION OF SURGICAL SITE INFECTION AND MOST COMMON PATHOGENS ACCORDING TO TYPE OF SURGERY: DATA REPORTED TO THE NATIONAL HEALTHCARE SAFETY NETWORK, 2015–2017 Type of Surgery Percentage of Reported Surgical Site Infections Most Common Pathogens Orthopedic 26% Staphylococcus aureus (39%), coagulase-negative staphylococci (34%), Pseudomonas aeruginosa (6%) Abdominal 52% Escherichia coli (20%), Enterococcus faecalis (10%), Klebsiella spp. (6%) Cardiac 5% S. aureus (25%), coagulase-negative staphylococci (13%), Pseudomonas aeruginosa (9%)
E. coli (14%), S. aureus (12%), Enterococcus faecalis (10%)
Obstetric/ gynecologic Neurologic
12%
2% Not reported 1% Not reported 0.1% Not reported
Vascular Prostate
Source: [146]
Table 9
Transmission and Common Pathogens Surgical site infections arise from both endogenous and exogenous transmission. The microbial sources of surgical site infections vary according to the type of surgery, and the micro-organism reported as being the most common in 2018–2021 was S. aureus , which accounted for more than one- third of all reported orthopedic surgical site infections [146]. Other common causative pathogens were coagulase-negative staphylococci, P. aeruginosa , and E. coli [146]. Among the facilities reporting data on surgical site infections to the NHSN in 2018–2021, the percentage of resistant phenotypes was low for pathogens most often associated with surgical site infections [146]. The percentage resistance for most pathogens decreased compared with data for 2007–2008; for example, 39% of S. aureus infections were resistant to oxa- cillins, a significant decrease from 48% in 2007–2008. The percentage of vancomycin-resistant E. faecium decreased from 56% in 2015–2017 to 49% in 2018–2021, and the percent- age of vancomycin-resistant E. faecalis decreased from 3.4% in 2015–2017 to 2.4% in 2018–2021 [146]. Rates of resistance of E. coli to extended-spectrum cephalosporins (26%) and of P. aeruginosa to aminoglycosides (12%) increased [146]. Prevention The CDC guideline for preventing surgical site infections, published in 1999, addresses a wide variety of issues, including preoperative preparation of the patient, antisepsis of the surgi- cal team, management of surgical personnel with colonization or infection, antimicrobial prophylaxis, ventilation, cleaning and disinfection of environmental surfaces, microbiologic sampling, sterilization of surgical instruments, surgical attire and drapes, asepsis and surgical technique, postoperative inci- sion care, and surveillance. The CDC’s current guideline for prevention of surgical site infection was published in 2017 [31; 175]. The guidelines recommend a combination of key compo- nents as a strategy to prevent surgical site infection ( Table 10 ).
Before surgery, patients should be advised to shower or bathe (full body) with soap (antibacterial or non-antibacterial) or an antiseptic agent on at least the night before the operative day [31]. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made [31]. Antibiotic prophylaxis need not be maintained longer than a few hours after the incision has been closed. Additional guidance is provided in reference to specific surgi- cal procedures and specialty operations (e.g., prosthetic joint arthroplasty) [31]. The CDC guidelines reference appropriate antibiotics on the basis of the type of surgery [31; 175]. Meta-analyses have demonstrated lower rates of infection with a single-dose (long- acting) antibiotic and broader spectrum antibiotics, such as third-generation cephalosporins [176]. However, a complica- tion of perioperative antibiotic prophylaxis is an increased frequency of adverse events, the most serious of which is infec- tion with C. difficile , and this risk may be higher in association with a broad-spectrum antibiotic [176]. Systematic reviews reported in the mid-2000s showed that two previously recommended measures for preventing post- operative infection have no effect on the rate of surgical site infection. One review involved six trials in which preoperative washing was evaluated in a total of 10,007 patients. There was no significant difference in the rate of surgical site infections when 4% chlorhexidine gluconate was compared with placebo or no washing [177]. The other review involved 11 randomized controlled trials in which preoperative hair removal practices were evaluated. Comparison of razor, depilatory cream, or no hair removal showed no significant difference in the rate of surgical site infection [178; 179]. However, when shaving was compared with clipping, there were significantly more surgical
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