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Media Gallery

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.

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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, 30]}

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* ^[31]

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 ^[32]

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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