_______________________________________________________________ Healthcare-Associated Infections
SURGICAL SITE INFECTIONS According to National Hospital Discharge Survey data, 51.4 million inpatient surgical procedures were performed in 2010, creating a large population at risk for surgical site infections [166]. The CDC healthcare-associated infection (HAI) prevalence survey found that there were an estimated 157,500 surgical site infections associated with inpatient sur- geries in 2011 [167]. Infection will develop postoperatively in approximately 2.6% of all patients who have surgery [168]. During 2018-–2021, surgical site infections contributed the highest proportion of pathogens (47.4%) compared with all other HAIs [146]. The rate has decreased since the 1990s, but the lower rate is not thought to be an accurate representation because of the increased number of operations done on an outpatient basis; a decrease in the length of the postoperative hospital stay; and a wound infection incubation period of 5 to 7 days [42]. This potential for underestimation of the number of surgical site infections is reflected in the findings of a study in which one-third of healthcare-associated wound infections were detected after the patient had been discharged [169]. Surgical site infections are associated with extended lengths of stay, a high rate of readmissions, excess hospital costs, and a mortality rate of 3%, with a higher mortality rate reported for patients 70 years of age and older [170; 171]. The NHSN program enables the CDC to monitor the dis- tribution, etiology, and antimicrobial resistance pattern of infections in relation to the category of surgical procedure. The number of surgical site infections reported through NHSN increased from 16,019 in 2009–2010 to 215,669 in 2018–2021 [146]. However, this may in part be a measure of improved surveillance, as the CDC reported a 19% decrease in infection associated with 10 select procedures performed between 2008 and 2013 [17]. The 2023 NHSN progress report showed a further 3% decrease in surgical site infections for 10 procedures tracked during the previous year [17]. Table 9 shows the distribution of procedure-associated infections and common pathogens, by type of surgery, as reported to NHSN for 2018–2021 [146]. Please note that the distribution percent- age is primarily a reflection of the frequency (commonality) with which the given category of surgery is performed and not an indication of the actual rate, or risk, of infection from the specific procedure itself. It may be seen that, with the exception of abdominal procedures, S. aureus (of which 45.5% of isolates were MRSA) accounted for the majority of these infections [146]. The category of surgery and the duration of the procedure are factors affecting the incidence of post-procedure surgical site infection. The rate of infection by type of surgery varies across facilities; for example, in a multicenter Veterans Administra- tion study, the overall rate of surgical site infection was 6%, with the highest rate (11.3%) following colorectal procedures and the lowest (1.3%) following orthopedic procedures [172].
Risk Factors Several patient-related and surgery-related factors increase the risk for surgical site infection. Patient-related factors include [31; 138; 142; 173]: • Older age (≥65 years) • Obesity • Poor nutritional status • Low serum albumin concentration • History of smoking • History of alcohol use disorders
• Existing infection • Diabetes mellitus • Trauma • Blood transfusion • Hypothermia, hypoxia, or hyperglycemia
Among the most common surgery-related factors are anesthe- sia score, duration of the operation, the use of drains, and inadequate aseptic technique [89]. In a study to determine the influence of risk factors on complications after colorectal surgery, body mass index, duration of the operation, and the surgeon who performed the operation were the three most important factors influencing surgical site infections [174].
Malnutrition is a recognized risk factor for surgical site infection, and the National Association of Orthopaedic Nurses recommends that postoperative patient and family education include maintenance of proper nutrition to avoid postoperative
complications. (https://www.brownhealth.org/sites/default/ files/2022-03/NAON-SSI-CPG%20-Final_2021.pdf. Last accessed January 26, 2025.) Level of Evidence : Consensus Statement/Expert Opinion 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].
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