Wound Infection Follow-up
- Author: Hemant Singhal, MD, MBBS, FRCSE, FRCS(C); Chief Editor: John Geibel, MD, DSc, MA more...
Further Inpatient Care
- Resultant increased hospital stay due to SSI has been estimated at 7-10 days, increasing hospitalization costs by 20%.[23, 29, 30]
- Occasionally, further intervention in the form of wound debridement and subsequent packing and frequent dressing is necessary to allow healing by secondary intention.
Further Outpatient Care
- Most patients with wound infections are managed in the community. Management usually takes the form of dressing changes to optimize healing, which usually is by secondary intention.
Breasted D. The Edwin Smith Surgical Papyrus. University of Chicago: University of Chicago Press; 1930.
Bryan PW. The Papyrus Ebers. London/Washington DC: Government Printing Office; 1883.
Cohen IK. A Brief History of Wound Healing. Yardley, Pa: Oxford Clinical Communications Inc; 1998.
Lister J. On a new method of treating compound fractures. Lancet. 1867;1:326-329,387-389,507-509.
Qvist G. Hunterian Oration, 1979. Some controversial aspects of John Hunter's life and work. Ann R Coll Surg Engl. Jul 1979;61(4):309-11. [Medline].
Helling TS, Daon E. In Flanders fields: the Great War, Antoine Depage, and the resurgence of débridement. Ann Surg. Aug 1998;228(2):173-81. [Medline].
Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev. Oct 1993;6(4):428-42. [Medline].
Mayon-White RT, Ducel G, Kereselidze T, et al. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect. Feb 1988;11 Suppl A:43-8. [Medline].
Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. Apr 1999;20(4):250-78; quiz 279-80. [Medline].
Kirkland KB, Briggs JP, Trivette SL, et al. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. Nov 1999;20(11):725-30. [Medline].
National Nosocomial Infections Surveillance (NNIS) System. NNIS report, data summary from October 1986-April 1996, issued May 1996. A report from the NNIS System. Am J Infect Control. Oct 1996;24(5):380-8. [Medline].
Di Leo A, Piffer S, Ricci F, et al. Surgical site infections in an Italian surgical ward: a prospective study. Surg Infect (Larchmt). Aug 18 2009;[Medline].
National Nosocomial Infections Surveillance (NNIS) System. NNIS report, data summary from January 1992 to June 2002, issued August 2002. Am J Infect Control. Dec 2002;30(8):458-75. [Medline].
Krizek TJ, Robson MC. Evolution of quantitative bacteriology in wound management. Am J Surg. Nov 1975;130(5):579-84. [Medline].
Hsiao CH, Chuang CC, Tan HY, Ma DH, Lin KK, Chang CJ, et al. Methicillin-Resistant Staphylococcus aureus Ocular Infection: A 10-Year Hospital-Based Study. Ophthalmology. Dec 14 2011;[Medline].
Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am. Feb 1980;60(1):27-40. [Medline].
Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery. Jul 1961;50:161-8. [Medline].
Barchitta M, Matranga D, Quattrocchi A, Bellocchi P, Ruffino M, Basile G, et al. Prevalence of surgical site infections before and after the implementation of a multimodal infection control programme. J Antimicrob Chemother. Nov 29 2011;[Medline].
Gupta R, Sinnett D, Carpenter R, et al. Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery. Eur J Surg Oncol. Jun 2000;26(4):363-6. [Medline].
Platt R, Zucker JR, Zaleznik DF, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother. Feb 1993;31 Suppl B:43-8. [Medline].
Woodfield JC, Beshay N, van Rij AM. A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone. A study of wound, chest, and urinary infections. World J Surg. Aug 2 2009;[Medline].
Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician. Jun 1998;57(11):2731-40. [Medline].
Mahmoud NN, Turpin RS, Yang G, et al. Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect (Larchmt). Aug 26 2009;[Medline].
Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med. Sep 16 1991;91(3B):152S-157S. [Medline].
Anesthesiology. New classification of physical status. Anesthesiology. 1963;24:111.
Pearson ML. Guideline for prevention of intravascular device-related infections. Part I. Intravascular device-related infections: an overview. The Hospital Infection Control Practices Advisory Committee. Am J Infect Control. Aug 1996;24(4):262-77. [Medline].
Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis. May 1 2001;32(9):1249-72. [Medline].
Dettenkofer M, Wilson C, Gratwohl A, et al. Skin disinfection with octenidine dihydrochloride for central venous catheter site care: a double-blind, randomized, controlled trial. Clin Microbiol Infect. Aug 17 2009;[Medline].
Haley RW, Schaberg DR, Crossley KB, et al. Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison. Am J Med. Jan 1981;70(1):51-8. [Medline].
Eagye KJ, Kim A, Laohavaleeson S, et al. Surgical site infections: does inadequate antibiotic therapy affect patient outcomes?. Surg Infect (Larchmt). Aug 2009;10(4):323-31. [Medline].
Baquero F. Gram-positive resistance: challenge for the development of new antibiotics. J Antimicrob Chemother. May 1997;39 Suppl A:1-6. [Medline].
Belda FJ, Aguilera L, Garcia de la Asuncion J, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. Oct 26 2005;294(16):2035-42. [Medline].
Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. Jun 15 2004;38(12):1706-15. [Medline].
Buggy D. Can anaesthetic management influence surgical-wound healing?. Lancet. Jul 29 2000;356(9227):355-7. [Medline].
Centers for Disease Control and Prevention. Prevent antimicrobial resistance in health care settings. Available at http://www.cdc.gov/drugresistance/healthcare/problem.htm.
Coello R, Charlett A, Wilson J, et al. Adverse impact of surgical site infections in English hospitals. J Hosp Infect. Jun 2005;60(2):93-103. [Medline].
Gaynes RP. Surgical-site infections (SSI) and the NNIS Basic SSI Risk Index, part II: room for improvement. Infect Control Hosp Epidemiol. May 2001;22(5):266-7. [Medline].
Heinzelmann M, Scott M, Lam T. Factors predisposing to bacterial invasion and infection. Am J Surg. Feb 2002;183(2):179-90. [Medline].
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. May 9 1996;334(19):1209-15. [Medline].
Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. Oct 2001;22(10):607-12. [Medline].
Nathens AB, Dellinger EP. Surgical site infections. Curr Treatment Options Infect Dis. 2000;2:347-348.
Nosocomial Infection National Surveillance Service (NINSS). Surgical site infection in English hospitals: a national surveillance and quality improvement program. Public Health Laboratory Service. 2002.
- Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence[11]
- Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used)[11, 16]
- Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved[11, 22]
- Table 4. American Society of Anesthesiologists (ASA) Classification of Physical Status[25]
- Table 5. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index*[24]
- Table 6. Data Support Recommendations
| 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 |
| 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 |
| 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 |
| 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 |
| 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) | |
| 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 | |

