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Wound Infection Treatment & Management

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

Approach Considerations

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.

Resultant increased hospital stay due to surgical site infection (SSI) has been estimated at 7-10 days, increasing hospitalization costs by 20%.[18, 19, 20] Occasionally, further intervention in the form of wound debridement and subsequent packing and frequent dressing is necessary to allow healing by secondary intention.

In 2014, the Infectious Diseases Society of America issued the following practice guidelines for the management of SSIs[21, 22] :

  • Suture removal plus incision and drainage should be performed for SSIs (strong recommendation, low-quality evidence)
  • Adjunctive systemic antimicrobial therapy is not routinely indicated but, in conjunction with incision and drainage, may be beneficial for SSIs associated with a significant systemic response, such as erythema and induration extending more than 5 cm from the wound edge, temperature exceeding 38.5°C, heart rate higher than 110 beats/min, or white blood cell (WBC) count higher than 12,000/µL (weak recommendation, low-quality evidence)
  • A brief course of systemic antimicrobial therapy is indicated in patients with SSIs after clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong recommendation, low-quality evidence)
  • A first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-sensitive S aureus (MSSA)—or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for methicillin-resistant S aureus (MRSA) are high (nasal colonization, prior MRSA infection, recent hospitalization, or recent antibiotics)—is recommended (strong recommendation, low-quality evidence)
  • Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal tract, perineum, or female genital tract (strong recommendation, low-quality evidence)
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Antibiotic Prophylaxis

The use of antibiotics was a milestone in the effort to prevent wound infection. The concept of prophylactic antibiotics was established in the 1960s when experimental data established that antibiotics had to be in the circulatory system at a high enough dose at the time of incision to be effective.[23, 24]

It is generally agreed that prophylactic antibiotics are indicated for clean-contaminated and contaminated wounds (see Table 2 in Overview). Antibiotics for dirty wounds are part of the treatment because infection is established already. Clean procedures might be an issue of debate. No doubt exists regarding the use of prophylactic antibiotics in clean procedures in which prosthetic devices are inserted; infection in these cases would be disastrous for the patient. However, other clean procedures (eg, breast surgery) may be a matter of contention.[25, 26]

Criteria for the use of systemic preventive antibiotics in surgical procedures are as follows:

  • Systemic preventive antibiotics should be used in the following cases: A high risk of infection is associated with the procedure (eg, colon resection); consequences of infection are unusually severe (eg, total joint replacement); the patient has a high NNIS risk index
  • The antibiotic should be administered preoperatively but as close to the time of the incision as is clinically practical Antibiotics should be administered before induction of anesthesia in most situations
  • The antibiotic selected should have activity against the pathogens likely to be encountered in the procedure
  • Postoperative administration of preventive systemic antibiotics beyond 24 hours has not been demonstrated to reduce the risk of SSIs

Qualities of prophylactic antibiotics include efficacy against predicted bacterial microorganisms most likely to cause infection (see Table 3 below), good tissue penetration to reach wound involved, cost effectiveness, and minimal disturbance to intrinsic body flora (eg, gut).[27]

Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved[8, 28] (Open Table in a new window)

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

 

The timing of administration is critically important because the concentration of the antibiotic should be at therapeutic levels at the time of incision, during the surgical procedure, and, ideally, for a few hours postoperatively.[8] Antibiotics are administered intravenously, generally 30 minutes prior to incision[28] ; they should not be administered more than 2 hours prior to surgery.

Colorectal surgical prophylaxis additionally requires bowel clearance with enemas and oral nonabsorbable antimicrobial agents 1 hour before surgery.[18] High-risk cesarean surgical cases require antibiotic administration as soon as the clamping of the umbilical cord is completed.[8]

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Risk Assessment

The current risk index used to predict the risk of developing a wound infection is the NNIS system of the CDC.[8] The risk index category is established by the added total of the risk factors present at the time of surgery. For each risk factor present, a point is allocated; risk index values range from 0-3. This risk index is a better predictor for SSIs (see Table 4 below) than the surgical wound classification is (see Table 2 in Overview).[29]

Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index*[29] (Open Table in a new window)

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)

The NNIS risk index integrates the three main determinants of infection—namely, bacteria, local environment, and systemic host defenses (patient health status). The risk index does not include other risk variables, like smoking, tissue oxygen tension, glucose control, shock, and maintenance of normothermia. All these factors are relevant for clinicians but difficult to monitor and fit into a manageable risk assessment.

The elements constituting this index are as follows:

  • Preoperative patient physical status assessed by the anesthesiologist and classified by the American Society of Anesthesiologists (see Table 5 below) as greater than 3
  • Operation status as either contaminated or dirty-infected (see Table 2 in Overview)
  • Operation lasting longer than T hours, where T is the 75th percentile of the specific operation performed

Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status[30] (Open Table in a new window)

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

 

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Perioperative Recommendations

Perioperative recommendations have been made for minimizing wound infection and SSI, supported by varying degrees of evidence (see Table 6 below).

Table 6. Data Support Recommendations (Open Table in a new window)

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

Preoperative patient preparation

Category IA recommendations for preoperative patient preparation include the following:

  • Identify and treat all infections remote from the surgical site; delay operation in elective cases until infection is treated
  • Do not remove hair unless it infringes on the surgical field; if hair removal is required, it should be removed immediately before operation and preferably with electric clippers

Category IB recommendations include the following:

  • Patients should cease tobacco consumption in any form for at least 1 month preoperatively
  • Optimize blood glucose level and avoid hyperglycemia
  • Patients are to shower/bathe with antiseptic on at least the night before surgery
  • Necessary blood products may be administered

The category II recommendation is as follows: Provided that preoperative patient preparation is adequate, minimize preoperative hospital stay.

No recommendations are made regarding the following:

  • Gradual reduction/discontinuance of steroid use before elective surgery
  • Enhanced nutritional intake solely to prevent SSI
  • Preoperative topical antibiotic use in nares to prevent SSI
  • Measures to enhance wound space oxygenation

Preoperative considerations for surgical team members

Category IB recommendations regarding preoperative considerations for surgical team members are as follows:

  • Keep fingernails short; do not wear artificial nails
  • Scrub hands and forearms as high as the elbows for at least 2-5 minutes with appropriate antiseptic
  • After scrub, keep hands up with elbows flexed and away from the body; use a sterile towel to dry the hands and put on a sterile gown and gloves
  • Masks should be worn in the operating suite if sterile instruments are exposed and throughout the surgical procedure; masks should cover the mouth and nose
  • The hair on the head and face is to be covered with a hood or cap
  • Liquid-resistant sterile surgical gowns and sterile gloves are to be worn by scrubbed surgical team members
  • Visibly soiled gowns are to be changed
  • Shoe covers are not necessary
  • Routine exclusion of personnel colonized by organisms, such as S aureus or group A streptococci, is not necessary unless they are specifically linked to dissemination of such organisms
  • Personnel with skin lesions that are draining are to be excluded from duty until treated and the infection has resolved
  • Educate and encourage surgical personnel regarding reporting illness of transmissible nature to supervisory and occupational health personnel
  • Policies should be established concerning patient care responsibilities for personnel with potentially transmissible infective illnesses, to include aspects of work restrictions, personnel responsibility in utilizing health services, and declaring illness; policies also should direct the responsible person to remove personnel from duty, and policy should be established for clearance to resume work

Category II recommendations are as follows:

  • Clean under the fingernails prior to the first scrub of the day
  • Do not wear arm/hand jewelry

No recommendations are made regarding the following:

  • Nail polish
  • Restriction of scrub suits to the operating theater
  • Covering the scrub suits when outside the theater
  • How or where to launder theater suites

Preoperative and postoperative wound care

A category IA recommendation for preoperative and postoperative wound care is that asepsis is necessary in the insertion of indwelling catheters, such as intravascular, spinal, or epidural catheters, and subsequent infusion of drugs. (See the image below.)

Abscess secondary to a subclavian line. Abscess secondary to a subclavian line.

Category IB recommendations include the following:

  • Handle tissues gently with good hemostasis, minimize foreign bodies, and minimize devitalized tissue and dead space
  • For class III and IV wounds, use delayed closure or leave the wound incision open to heal by secondary intention
  • If draining of a wound is necessary, the drain exit should be via separate incision distant from the wound; remove the drain as soon as possible
  • Primary closed incisions should be protected with a sterile dressing for 24-48 hours
  • Hands are to be washed before and after wound dressing changes/or contact

Category II recommendations include the following:

  • Use sterile technique for wound dressing change
  • Educate the patient and relatives regarding wound care symptoms of SSIs and the need to report such problems

Theater environment and care of instrumentation

Category IB recommendations for the theater environment and the care of instrumentation include the following:

  • Maintain positive-pressure ventilation of the operating suite relative to corridors and surrounding areas
  • Maintain a minimum of 15 air changes per hour, with at least three being fresh air
  • Appropriate filters (as recommended by the American Institute of Architects) should be used for filtration of all air, whether recirculated or fresh
  • Air should enter through the ceiling and exit near the floor
  • Keep operating room doors closed except for necessary entry
  • The use of ultraviolet lamps in the theater is not necessary as a deterrent of SSI
  • Prior to subsequent procedures, visibly soiled surfaces should be cleaned with Environmental Protection Agency (EPA)–approved disinfectants
  • After a contaminated or dirty procedure, special cleaning or closure of the operating suite is not necessary
  • Use of tacky mats prior to entry in the operating suite is not necessary
  • Sterile surgical instruments and solutes should be assembled just prior to use
  • All surgical instruments should be sterilized according to guidelines; flush sterilization should only be used for instruments that are required for immediate patient use

Category II recommendations include the following:

  • Limit the number of personnel entering the operating suite.
  • Orthopedic implant surgery should be performed in an ultraclean-air environment.
  • Wet-vacuum the floor of the operating theater at the end of day/night using an EPA-approved disinfectant

Special situations

Elective colon surgery

Bowel surgery results in the breakdown of the protective intestinal mucous membrane, with release of the facultative and anaerobic bacteria that heavily colonize the distal small bowel and colon. Eradication of aerobes and anaerobes is necessary to reduce infective complications following intestinal procedures. Mechanical cleansing and antibiotics could achieve this.

Mechanical cleansing can take the form of dietary restrictions; whole gut lavage with one of several preparations, such as 10% mannitol solution, Fleet's phospho-soda, or polyethylene glycol, usually is performed on the day of surgical intervention. Enteral antibiotic regimes to eradicate intrinsic bowel flora vary, with oral neomycin and erythromycin being the most popular combination in the United States. Other combinations with neomycin include the use of metronidazole and tetracycline. Prophylactic parenteral antibiotics also are used with the above.

Intravascular device-related infections

Intravascular devices are of vital use in daily hospital practice. They are used for the parenteral administration of fluids, blood products, nutritional fluids, and medication and for access in hemodialysis; equally important is their use in the monitoring of critically ill patients.

Unfortunately, because the use of these devices constitutes an invasive procedure, they are associated with infectious complications that could be of a local or systemic nature. Recommendations for prevention[31] and treatment[32] are available to limit their associated morbidity and mortality (which could be as high as 20% in patients with catheter-related bloodstream infections).

In a double-blind, randomized, controlled study of 400 patients with nontunnelled central venous catheters, Dettenkofer et al investigated the effectiveness of the antiseptic octenidine dihydrochloride, used in combination with alcohol-based antiseptic, against infection at central venous catheter insertion sites.[33] One group of patients received skin disinfection with 0.1% octenidine with 30% 1-propanol and 45% 2-propanol, while a control group was disinfected with 74% ethanol with 10% 2-propanol.

In this study, microbial skin colonization at the catheter insertion site and positive microbial cultures at the catheter tip were significantly reduced in the octenidine group.[33] No significant differences in catheter-associated bloodstream infections were found between the groups.

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Surgical Care

Although the goal of every surgeon is to prevent wound infections, they will arise. Treatment is individualized to the patient, the wound, and the nature of the infection. The operating surgeon should be made aware of the possibility of infection in the wound and determine the treatment for the wound.

Ideally, surgical care should start with meticulous detail to strategies that prevent the development of SSIs in the first place. Preoperatively, attention should be paid to factors like optimization of patient status, proper asepsis, and surgical site preparation. Intraoperatively, adherence to good basic surgical principles of minimal and fine tissue dissection, proper selection of suture materials, and proper wound closure is important.

If a SSI sets in, the treatment often involves opening the wound, evacuating pus, and cleansing the wound. The deeper tissues are inspected for integrity and for a deep space infection or source. Dressing changes allow the tissues to granulate, and the wound heals by secondary intention over several weeks. Early/delayed closure of infected wounds is often associated with relapse of infection and wound dehiscence.

Additional preventive strategies

Evidence shows that the close regulation of blood sugar may be a major determinant of wound morbidity.[34] Although investigators have vigorously pursued for decades the identification of a specific innate or acquired immune deficiency among patients with diabetes, it may be the blood sugar that is the determinant of infection for these patients.

A second issue of considerable interest is body temperature. A prospective randomized study demonstrated that failure to maintain intraoperative core body temperature within 1-1.5°C of normal increases the SSI rate by a factor of 2.[35] It raises the scientific question of whether increasing core temperature during operations over normal temperature might in fact protect against infection.

A third issue is oxygenation.[36] The fresh, hemostatic surgical incision is a hypoxic, ischemic environment. Maintaining or increasing oxygen delivery to the wound by increasing the inspired oxygen concentration administered to the patient perioperatively has also been shown to reduce the incidence of SSIs. It is presumed that increased oxygen availability is a positive host factor, perhaps via enhanced production of oxidant products that facilitate phagocytic eradication of microbes.

A strategy that could bear fruit for preventing SSIs in the future is the establishment of dedicated infection surveillance units in hospitals with the aim of accomplishing the following:

  • Identify epidemics by common or uncommon organisms
  • Establish the correct use of prophylaxis (ie, timing, dose, duration, choice)
  • Document costs, risk factors, and readmission rates
  • Monitor postdischarge infections and secondary consequences
  • Ensure patient safety

A major concern is how to prevent or minimize the emergence of resistance. Although resistance is not a new phenomenon, the incidence has increased dramatically over the past two decades. The development of new drugs has slowed considerably and may be unable to keep pace with the continuing growth of pathogen resistance.

Accordingly, effective strategies are needed to prevent the continuing emergence of antimicrobial resistance. These strategies include avoiding unnecessary antibiotic administration and increasing the effectiveness of prescribed antibiotics, as well as implementing improvements in infection control and optimizing medical practice.

Although an SSI rate of zero may not be achievable, continued progress in understanding the biology of infection at the surgical site and consistent applications of proven methods of prevention will further reduce the frequency, cost, and morbidity associated with SSIs.

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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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