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Wound Infection Clinical Presentation

  • Author: Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 17, 2015
 

Definition and Classification

Surgical site infection (SSI) is a difficult term to define accurately because it has a wide spectrum of possible clinical features.

The Centers for Disease Control and Prevention (CDC) has defined SSI to standardize data collection for the National Nosocomial Infections Surveillance (NNIS) program.[8, 16] SSIs are classified into incisional SSIs, which can be superficial or deep, and organ/space SSIs, which affect the rest of the body other than the body wall layers (see the image below). These classifications are defined as follows:

  • Superficial incisional SSI - Infection involves only skin and subcutaneous tissue of incision
  • Deep incisional SSI - Infection involves deep tissues, such as fascial and muscle layers; this also includes infection involving both superficial and deep incision sites and organ/space SSI draining through incision
  • Organ/space SSI - Infection involves any part of the anatomy in organs and spaces other than the incision, which was opened or manipulated during operation
Definitions of surgical site infection (SSI). Definitions of surgical site infection (SSI).

Superficial incisional SSI is more common than deep incisional SSI and organ/space SSI. Superficial incisional SSI accounts for more than half of all SSIs for all categories of surgery. The postoperative length of stay is longer for patients with SSI, even when adjusted for other factors influencing length of stay.

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History and Physical Examination

A report by the NNIS program[17] cited particular clinical findings as characteristic of the different types of SSI.

Superficial incisional SSI is characterized by the following:

  • Occurs within 30 days after the operation
  • Involves only the skin or subcutaneous tissue
  • Includes at least one of the following: (a) purulent drainage is present (culture documentation not required); (b) organisms are isolated from fluid/tissue of the superficial incision; (c) at least one sign of inflammation (eg, pain or tenderness, induration, erythema, local warmth of the wound) is present; (d) the wound is deliberately opened by the surgeon; (e) the surgeon or clinician declares the wound infected
  • Note: A wound is not considered a superficial incisional SSI if a stitch abscess is present; if the infection is at an episiotomy, a circumcision site, or a burn wound; or if the SSI extends into fascia or muscle

Deep incisional SSI is characterized by the following:

  • Occurs within 30 days of the operation or within 1 year if an implant is present
  • Involves deep soft tissues (eg, fascia and/or muscle) of the incision
  • Includes at least one of the following: (a) purulent drainage is present from the deep incision but without organ/space involvement; (b) fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation; (c) a deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination; (d) the surgeon or clinician declares that a deep incisional infection is present

Organ/space SSI is characterized by the following:

  • Occurs within 30 days of the operation or within 1 year if an implant is present
  • Involves anatomic structures not opened or manipulated during the operation
  • Includes at least one of the following: (a) purulent drainage is present from a drain placed by a stab wound into the organ/space; (b) organisms are isolated from the organ/space by aseptic culturing technique; (c) an abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination; (d) a diagnosis of organ/space SSI is made by the surgeon or clinician

Examples of wound infections are shown in the images below.

Wound infection due to disturbed coagulopathy. Thi Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
Abscess secondary to a subclavian line. Abscess secondary to a subclavian line.
Large ulceration in a tattoo. A 33-year-old man pr Large ulceration in a tattoo. A 33-year-old man presented with a superficial ulceration about 4 weeks after a red tattoo on his forearm. Microbial swabs remained negative. His medical history was uneventful and he was in good general health. No reason for this uncommon reaction could be identified. Image courtesy of the National Institutes of Health.
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Contributor Information and Disclosures
Author

Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC Consultant Surgeon, Clementine Churchill Hospital; Director of Breast Service, Medanta The Medicity; Senior Lecturer, Department of Surgery, Imperial College School of Medicine

Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Kanchan Kaur, MBBS MS (General Surgery), MRCS (Ed), Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: Association for Academic Surgery, International College of Surgeons, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, Association of Women Surgeons, International Liver Transplantation Society, Transplantation Society, American College of Surgeons, American Medical Association, American Medical Womens Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Charles Zammit, MD Senior Specialist Registrar, Department of Surgery, Breast Unit Charing Cross Hospital of London, UK

Disclosure: Nothing to disclose.

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Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
Abscess secondary to a subclavian line.
Definitions of surgical site infection (SSI).
Factors that affect surgical wound healing.
Large ulceration in a tattoo. A 33-year-old man presented with a superficial ulceration about 4 weeks after a red tattoo on his forearm. Microbial swabs remained negative. His medical history was uneventful and he was in good general health. No reason for this uncommon reaction could be identified. Image courtesy of the National Institutes of Health.
Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence [8]
Pathogen Frequency (%)
Staphylococcus aureus 20
Coagulase-negative staphylococci 14
Enterococci 12
Escherichia coli 8
Pseudomonas aeruginosa 8
Enterobacter species 7
Proteus mirabilis 3
Klebsiella pneumoniae 3
Other streptococci 3
Candida albicans 3
Group D streptococci 2
Other gram-positive aerobes 2
Bacteroides fragilis 2
Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used) [8, 10]
Classification Description Infective Risk (%)
Clean (Class I) Uninfected operative wound



No acute inflammation



Closed primarily



Respiratory, gastrointestinal, biliary, and urinary tracts not entered



No break in aseptic technique



Closed drainage used if necessary



< 2
Clean-contaminated (Class II) Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage



No evidence of infection or major break in aseptic technique



Example: appendectomy



< 10
Contaminated (Class III) Nonpurulent inflammation present



Gross spillage from gastrointestinal tract



Penetrating traumatic wounds < 4 hours



Major break in aseptic technique



About 20
Dirty-infected (Class IV) Purulent inflammation present



Preoperative perforation of viscera



Penetrating traumatic wounds >4 hours



About 40
Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved [8, 28]
Operation Expected Pathogens Recommended Antibiotic
Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic procedures S aureus, coagulase-negative staphylococci Cefazolin 1-2 g
Appendectomy, biliary procedures Gram-negative bacilli and anaerobes Cefazolin 1-2 g
Colorectal surgery Gram-negative bacilli and anaerobes Cefotetan 1-2 g or cefoxitin 1-2 g plus oral neomycin 1 g and oral erythromycin 1 g (start 19 h preoperatively for 3 doses)
Gastroduodenal surgery Gram-negative bacilli and streptococci Cefazolin 1-2 g
Vascular surgery S aureus, Staphylococcusepidermidis, gram-negative bacilli Cefazolin 1-2 g
Head and neck surgery S aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approach Cefazolin 1-2 g
Obstetric and gynecological procedures Gram-negative bacilli, enterococci, anaerobes, group B streptococci Cefazolin 1-2 g
Urology procedures Gram-negative bacilli Cefazolin 1-2 g
Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index* [29]
At Risk



Index



Predictive Percentage of SSI
0 1.5
1 2.9
2 6.8
3 13.0
*Hospital Infection Control Practices Advisory Committee (HICPAC) recommendations (partial) for the prevention of SSIs, April 1999 (non–drug based)
Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status [30]
ASA Score Characteristics
1 Normal healthy patient
2 Patient with mild systemic disease
3 Patient with a severe systemic disease that limits activity but is not incapacitating
4 Patient with an incapacitating systemic disease that is a constant threat to life
5 Moribund patient not expected to survive 24 hours with or without operation
Table 6. Data Support Recommendations
Category Description
Category IA Well designed, experimental, strong; recommended (Category I*) clinical or epidemiological best practice; should be studies; adapted by all practices
Category IB Some experimental, fairly strong; recommended (Category II*) clinical or epidemiological best practice; should be studies and theoretical grounds; adapted by all practices
Category II Fewer scientific supporting data; limited to specific nosocomial (Category III*) problems
No recommendation Insufficient scientific personnel judgment for use (Category III*) supporting data
*Previous nomenclature of 1992 CDC guidelines
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