Surgical site infection (SSIs) imposes a substantial burden on healthcare systems, affecting between 160,000 and 300,000 surgical patients annually in the United States alone. These infections not only increase patient morbidity and mortality but also strain financial resources, with costs ranging from $3.5 to $10 billion. Despite improvements in surgical techniques and antibiotic prophylaxis, surgical site infection remains a significant concern in patient care.

Although the incidence of surgical site infection has declined in recent years due to advances in aseptic methods, they still represent a leading cause of postoperative complications. Surgical site infection often results in extended hospital stays, additional treatments, and sometimes secondary surgeries, which increase healthcare costs. Preventing these infections is critical to reducing their clinical and financial burdens on healthcare systems and patients. Implementing standardized protocols and metrics is crucial to prevent surgical site infections and reduce their impact on healthcare systems.

What Are Surgical Site Infections?

According to the CDC, infected incisions that occur 30 days postoperatively or 90 days in case of a surgical implant are called "surgical site infections." Initially, they were called "surgical wound infections," but the term was replaced in 1992. Before the advent of laparoscopic and minimally invasive procedures, surgical procedures resulted in the creation of an external wound. Therefore, a surgical wound undergoes the same healing stages as a wound from any other cause.

Wound healing and its stages may be affected by the characteristics of the surgical incision and the presence of infection. An ideal surgical wound is sterile and heals rapidly without any complications. Unfortunately, bacteria and other microorganisms at the wound site can significantly delay wound healing and lead to tissue breakdown.

Surgical site infection can be classified according to the degree of tissue involvement. The main types of surgical site infection include:

• Superficial Incisional SSI: affects the skin and subcutaneous tissue.
• Deep Incisional SSI: affects deeper tissues, including fascia and muscles.
• Organ Space SSIs: affects internal/vital organs.

Definition and Classification

Surgical site infections (SSIs) occur after a surgical procedure, typically within 30 days of the operation. According to the Centers for Disease Control and Prevention (CDC), an SSI is an infection related to an operative procedure that occurs at or near the surgical incision. These infections can be classified into three main categories: superficial incisional, deep incisional, and organ/space infections.

Superficial incisional SSIs involve only the skin and subcutaneous tissue of the incision. These are often the least severe but can cause significant discomfort and delay healing. Deep incisional SSIs, on the other hand, affect deeper tissues, such as the fascial and muscle layers, posing a greater risk to the patient’s health. Organ/space SSIs are the most severe, affecting internal organs and spaces that were opened or manipulated during the operation. These infections can lead to severe complications and require prompt medical intervention.

Understanding the classification of SSIs is crucial for effective disease control and management. By identifying the type of infection, healthcare providers can tailor their treatment strategies to address the patient's specific needs, thereby improving outcomes and reducing the risk of further complications.

Risk Factors

Several intrinsic and extrinsic risk factors influence the development of surgical site infection (SSIs). Intrinsic factors, such as a patient’s age, overall health, and pre-existing conditions like diabetes, can compromise the immune system and make the body more susceptible to infection. These factors are typically non-modifiable, but understanding their role is crucial in planning personalized care for patients undergoing surgery. For example, patients with chronic illnesses may require closer monitoring or specific preoperative interventions to mitigate these risks.

Extrinsic factors, on the other hand, include elements related to the surgical environment and practices. These factors can range from the length of surgery, the sterility of surgical instruments, and the cleanliness of the operating room to the surgical team’s skill. Extrinsic risks are largely modifiable, meaning healthcare teams can intervene by ensuring strict adherence to sterile techniques, maintaining optimal hygiene standards, and minimizing operative time. Additionally, the judicious use of antibiotic prophylaxis can further reduce infection risks or even the signs of infection after surgery.

Due to the detrimental impact that surgical site infection (SSIs) has on wound healing and patient outcomes, identifying and addressing modifiable risks is essential. Surgeons and wound care specialists can adjust surgical techniques, enhance preoperative care, and deliver focused post-operative care to mitigate the risks associated with surgical site infection. By doing so, they can prevent infections, accelerate recovery, and improve overall patient health. The earlier these risks are detected and managed, the better the chances for smooth wound healing and reduced complications.

Several factors contribute to the risk of developing surgical site infection, many of which can be addressed through careful planning and intervention. These factors range from patient-related issues, such as diabetes and obesity, to procedural aspects, such as the cleanliness of instruments and skin preparation techniques. Below are some of the critical risk factors that have been identified in the development of surgical site infection:

• Diabetes mellitus
• Obesity
• Low albumin levels
• Immunosuppression
• Increasing age
• Previous history of skin or soft tissue infection
• Malnutrition
• Local factors: open surgery, contaminated instruments, poor skin preparation
• Smoking
• Implants
• Recent hospitalization

Wound Care For Surgical Site Infection (SSIs)

As most surgical patients are discharged soon after the procedure, surgical teams miss the majority of surgical site infection, which usually take time to develop. Thus, patients and their caregivers should be informed about proper wound care and clinical signs that signal the onset of infection. They should also be told to contact wound care specialists in case of a suspected surgical site infection.

The following are the principles of management for surgical site infections:

• Obtain Imaging and Cultures: A CT scan or MRI can diagnose deep-seated infections. Ultrasound can also identify the presence of fluid in subcutaneous tissues. In case of suspected surgical site infection (SSI), a gram stain and culture should be obtained from the wound site. The swab should be obtained from the site instead of the surrounding skin.
• Wound Exploration and Debridement: A suspected surgical site infection should be opened for wound exploration. Surgical sutures and staples should be removed, and wound edges should be separated to allow for the drainage of infected fluid. This also enables wound care specialists to assess the extent of infection and tissue involvement. Cultures should be obtained from the infected fluid. The wound should be irrigated with normal saline.

Moreover, debridement is recommended to remove the necrotic tissue, as it aids in improving wound healing. Debridement is essential in necrotizing soft tissue infections, requiring immediate intervention to prevent severe complications. Foreign bodies should also be removed from the surgical wound site, as their presence can delay wound healing.‍

• Antibiotics: Antibiotics are recommended for treating deep incisional surgical site infections and organ space surgical site infection. However, antibiotics should only be administered when the following clinical signs and symptoms are present:
  • Cellulitis and erythema of surrounding skin
  • Implants
  • Systemic signs of infection (e.g, high-grade fever).

• Wound Dressing: Moist dressing is preferred in managing surgical wounds as it allows for retaining the required growth factors for healing. Normal saline should moisten the gauze, and layers of dry gauze should be placed over it. The dressing should be changed regularly, as instructed by the healthcare provider before the granulation tissue starts appearing. An ideal dressing should retain moisture, have microbicidal properties, and not damage the granulation tissue.
• Negative Pressure Wound Therapy (NPWT): Negative pressure wound therapy can manage surgical wounds. It allows for fewer dressing changes and has been found to promote wound healing. However, using NPWT early in surgical site infection might be counterintuitive and controversial.
• Wound Reconstruction: Wounds with tissue loss due to debridement might require skin grafts to provide adequate coverage to the wound site. Insufficient nutrition and wound care should be addressed for the best results.

Complications and Prognosis

Surgical site infections can lead to complications, including delayed wound healing, abscess formation, and sepsis. In severe cases, SSIs can result in organ failure or exacerbate existing comorbid conditions, significantly impacting the patient’s overall health. The prognosis for patients with SSIs depends on several factors, including the severity of the infection, the promptness and effectiveness of treatment, and the patient’s overall health status.

Early surgical site infection recognition and treatment are crucial for achieving the best possible outcomes. Studies have shown that physiological factors, tumor characteristics, and the type of surgery are reliable predictive factors for developing surgical site infections. Surgical factors such as the type of procedure, whether the surgery was an emergency, the wound class, and the surgeon’s experience are also independent risk factors for surgical site infections.

By understanding these risk factors, healthcare providers can implement targeted strategies to prevent surgical site infection and manage them effectively when they occur. This proactive approach can help mitigate the complications associated with SSIs, improve patient outcomes, and reduce the overall burden on healthcare systems.

Guidelines and Training

Preventing surgical site infections requires a multifaceted approach that involves adherence to evidence-based guidelines and protocols. The CDC has developed comprehensive guidelines summarizing the evidence for clinical interventions to prevent SSIs. These guidelines cover various aspects of surgical care, including antimicrobial prophylaxis, proper wound care, and infection control practices.

Healthcare providers can significantly reduce the risk of SSIs by following best practices such as:

• Administering appropriate antimicrobial prophylaxis to prevent infection.
• Maintaining proper wound care and dressing techniques to promote healing.
• Implementing stringent infection control practices, including hand hygiene and sterilization of equipment.
• Providing patient education on wound care and infection prevention empowers patients to recover.
• Encouraging patients to promptly report any signs or symptoms of infection for early intervention.

Training and education are essential for healthcare providers to stay up-to-date on the latest guidelines and best practices for preventing SSIs. For example The World Health Organization (WHO) offers educational resources and training programs focused on infection prevention and control, including surgical site infection prevention. By participating in these programs, healthcare providers can enhance their knowledge and skills, ultimately improving patient care and outcomes.

By adhering to these guidelines and continuously updating their training, healthcare providers can reduce surgical site infection risk effectively, ensuring better patient health outcomes.

Prevention of Surgical Site Infections - The Role of Telehealth

Surgical site infections (SSIs) are preventable with adequate postoperative care and monitoring. Telehealth can help wound care specialists, podiatrists, and surgeons provide continuity of care to patients after discharge. It can be an excellent alternative for patients who cannot access healthcare facilities readily. Monitoring chronic wounds by podiatrists and wound care specialists using telemedicine facilities has been studied with promising results—similar studies studying the effectiveness of telehealth in diagnosing surgical site infection found around 69.5% to 100% accuracy. Telehealth services can help prevent complications associated with surgical site infection via early detection and management. Telehealth can also significantly prevent other healthcare-associated infections by providing continuous monitoring and early intervention.