Abstract and purpose
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Summary of major changes
This section lists major changes from the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update,1 including recommendations that have been added, removed, or altered. Recommendations are categorized as essential practices that should be adopted by all acute-care hospitals (in 2014 these were “basic practices,” renamed to highlight their importance as a foundation for hospitals’ healthcare-associated infection (HAI) prevention programs) or additional approaches that can be considered for use in locations and/or populations within hospitals when SSIs are not controlled after implementation of essential practices (in 2014 these were called “special approaches”). See Table 1 for a complete summary of recommendations contained in this document.
Table 1.
Summary of Recommendations to Prevent Surgical Site Infections (SSIs)
Essential practices |
---|
1. Administer antimicrobial prophylaxis according to evidence-based standards and guidelines.73,75 (Quality of evidence: HIGH) |
2. Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI.115,116 (Quality of evidence: HIGH) |
3. Decolonize surgical patients with an anti-staphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (Quality of evidence: HIGH) Decolonize surgical patients in other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (Quality of evidence: LOW) |
4. Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (Quality of evidence: MODERATE) |
5. Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure.4,119 (Quality of evidence: MODERATE) |
6. Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (Quality of evidence: HIGH) |
7. For procedures not requiring hypothermia, maintain normothermia (temperature > 35.5°C) during the perioperative period. (Quality of evidence: HIGH) |
8. Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (Quality of evidence: HIGH) |
9. Perform intraoperative antiseptic wound lavage.171 (Quality of evidence: MODERATE) |
10. Control blood-glucose level during the immediate postoperative period for all patients.94 (Quality of evidence: HIGH) |
11. Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (Quality of evidence: HIGH) |
12. Perform surveillance for SSI. (Quality of evidence: MODERATE) |
13. Increase the efficiency of surveillance by utilizing automated data. (Quality of evidence: MODERATE) |
14. Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (Quality of evidence: MODERATE). |
15. Measure and provide feedback to HCP regarding rates of compliance with process measures.94 (Quality of evidence: LOW) |
16. Educate surgeons and perioperative personnel about SSI prevention measures. (Quality of evidence: LOW) |
17. Educate patients and their families about SSI prevention as appropriate. (Quality of evidence: LOW) |
18. Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and medical device manufacturer instructions for use.4,94 (Quality of evidence: MODERATE) |
19. Observe and review operating room personnel and the environment of care in the operating room and in central sterile reprocessing. (Quality of evidence: LOW) |
Additional approaches |
1. Perform an SSI risk assessment. (Quality of evidence: LOW) |
2. Consider use of negative pressure dressings in patients who may benefit. (Quality of evidence: MODERATE) |
3. Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit and/or surgical ward. (Quality of evidence: MODERATE) |
4. Use antiseptic-impregnated sutures as a strategy to prevent SSL (Quality of evidence: MODERATE) |
Approaches that should not be considered a routine part of SSI prevention |
1. Do not routinely use vancomycin for antimicrobial prophylaxis.73 (Quality of evidence: MODERATE) |
2. Do not routinely delay surgery to provide parenteral nutrition. (Quality of evidence: HIGH) |
3. Do not routinely use antiseptic drapes as a strategy to prevent SSL (Quality of evidence: HIGH) |
Unresolved issues |
1. Optimize tissue oxygenation at the incision site |
2. Preoperative intranasal and pharyngeal CHG treatment for patients undergoing cardiothoracic procedures |
3. Use of gentamicin-collagen sponges |
4. Use of antimicrobial powder |
5. Use of surgical attire |
Essential practices
Modified recommendation to administer prophylaxis according to evidence-based standards and guidelines to emphasize that antimicrobial prophylaxis should be discontinued at the time of surgical closure in the operating room.
The use of parenteral and oral antibiotics prior to elective colorectal surgery is now considered an essential practice. This recommendation was included in the 2014 document but was a sub-bullet recommendation. This recommendation was elevated to its own recommendation for increased emphasis.
Reclassified decolonization of surgical patients with an anti-staphylococcal agent for cardiothoracic and orthopedic procedures from an Additional Approach to an Essential Practice.
The use of vaginal preparation with an antiseptic solution prior to cesarean delivery and hysterectomy was added as an essential practice.
Reclassified intraoperative antiseptic wound lavage from an Additional Approach to an Essential Practice. However, this approach should only be used when sterility of the antiseptic can be ensured and maintained.
Control of blood-glucose levels during the immediate postoperative period for all patients was modified (1) to emphasize the importance of this intervention regardless of a known diagnosis of diabetes mellitus, (2) to elevate the evidence level to “high” for all procedures, and (3) to lower the target glucose level from <180 mg/dL to 110–150 mg/dL.
Reclassified use of bundles to promote adherence with best practices from Unresolved to an Essential Practice. Discussion of the use of checklists and bundles was combined for this recommendation.
Reclassified observe and review operating room personnel and the environment of care in the operating room and central sterile reprocessing from an Additional Approach to an Essential Practice.
Additional approaches
Reclassified the recommendation to perform an SSI risk assessment from an Essential Practice to an Additional Approach.
The use of negative pressure dressings was added as an Additional Practice. To date, available evidence suggests that this strategy is most likely effective in specific procedures (eg, abdominal procedures) and/or specific patients (eg, increased body mass index).
Reclassified the use of antiseptic-impregnated sutures from Not Recommended to Additional Approaches.
Not recommended
Expanded discussion on the recommendation against the routine use of vancomycin for antimicrobial prophylaxis.
Unresolved issues
Reclassified the use of supplemental oxygen for patients requiring mechanical ventilation from an Essential Practice to Unresolved.
Added discussion on the use of antimicrobial powder.
Added discussion on the use of surgical attire as a strategy to prevent SSI.
Intended Use
This document was developed following the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents.2 No guideline or expert guidance document can anticipate all clinical situations, and this document is not meant to be a substitute for individual clinical judgment by qualified professionals.
This document is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, writing-group consensus, and consideration of potential harm, when applicable. A summary list of recommendations is provided along with the relevant rationale in Table 1.
Methods
SHEA recruited 3 subject-matter experts in the prevention of SSI to lead the panel of members representing the Compendium partnering organizations—SHEA, IDSA, APIC, AHA, and The Joint Commission, as well as representation by the Centers for Disease Control and Prevention (CDC).
SHEA utilized a consultant medical librarian, who developed a comprehensive search strategy for PubMed and Embase (January 2012–July 2019, updated to August 2021). Article abstracts were reviewed by panel members. Each abstract was reviewed by at least 2 reviewers using the abstract management software Covidence (Melbourne, Australia), and selected abstracts were reviewed as full text. In July 2021, the Compendium Lead Authors group voted to update the literature findings, and the librarian re-ran the search to update it to August 2021. Panel members reviewed the search yield via Covidence and incorporated relevant references.
Recommendations resulting from this literature review process were classified based on the quality of evidence and the balance between desirable and potential for undesirable effects of various interventions (Table 2). Panel members met via video conference to discuss literature findings; recommendations; quality of evidence for these recommendations; and classification as essential practices, additional practices, or unresolved issues. Panel members reviewed and approved the document and its recommendations.
Table 2.
Quality of Evidencea
HIGH | Highly confident that the true effect lies close to that of the estimated size and direction of the effect, for example, when there are a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval. |
MODERATE | The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different, for example, when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide. |
LOW | The true effect may be substantially different from the estimated size and direction of the effect, for example, when supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very wide, or there are no rigorous studies. |
Based on the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) “Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Recommendations Categorization Scheme for Infection Control and Prevention Guideline Recommendations” (October 2019), the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE),339 and the Canadian Task Force on Preventive Health Care.340
The Compendium Expert Panel, made up of members with broad healthcare epidemiology, surgical, and infection prevention expertise, reviewed the draft manuscript after consensus had been reached by writing-panel members.
Following review and approval by the Expert Panel, the 5 Compendium partners, collaborating professional organizations, and CDC reviewed the document. Prior to dissemination, the guidance document was reviewed and approved by the SHEA Guidelines Committee, the IDSA Practice Standards and Guidelines Committee, AHA, and The Joint Commission, and the Boards of SHEA, IDSA, and APIC.
All panel members complied with the SHEA and IDSA policies on conflict-of-interest disclosure.
Section 1: Rationale and statements of concern
Burden of outcomes associated with SSI
- Surgical site infections (SSIs) are common complications in acute-care facilities.
- Additional data on ambulatory and outpatient surgeries are needed. Overall, many of these procedures are lower risk by virtue of procedure type and patient selection, and some may involve minimally invasive techniques that have a lower risk of infection.5,6 It is important to mention, however, that both inpatient and ambulatory operating rooms need to adhere to strict infection prevention standards.
Up to 60% of SSIs are preventable using evidence-based guidelines.12,13
When not prevented, SSIs can result in a significant increase in postoperative hospital days and many also require reoperation, both during the initial surgical admission and during hospital readmission.11,14-16
Patients with an SSI have a 2–11 times higher risk of death compared to operative patients without SSI.17,18 Also, 77% of deaths in patients with SSI are directly attributable to SSI.19
Attributable costs of SSI vary depending on the type of operative procedure, medical implants, and the type of infecting pathogen.16,18,20-27 Overall, it is estimated that the cost of care for patients who develop an SSI is 1.4–3 times higher than for patients who do not develop an SSI.28 Deep-incisional and organ-space SSIs are associated with the highest cost.28 All studies evaluated in a systematic review reported some economic benefit associated with SSI prevention, but there is significant heterogeneity in the literature related to cost accounting.29,30 In the United States, SSIs are believed to account for $3.5 billion to $10 billion annually in healthcare expenditures.31,32
Finally, data reported to the CDC NHSN show that SSIs can be caused by antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and multidrug-resistant gram-negative bacilli. These infections can be more difficult to manage and can be caused by pathogens that are resistant to standard empiric antibiotics.33
Risk factors for SSI
Numerous risk factors have been described for SSI, including intrinsic factors, patient-specific risk factors, and perioperative factors related to surgical practices (Table 3). Some common patient-specific risk factors include obesity, diabetes, immuno-suppressive therapy, malnutrition, and smoking. In pediatrics, premature infants are also at higher risk, especially those undergoing gastrointestinal surgery early in life. Examples of perioperative risk factors include inadequacies in surgical scrub, the antiseptic preparation of the skin, antimicrobial prophylaxis, and duration of surgery.
The CDC NHSN–determined risk factors for different procedure categories are incorporated in the calculation of the standardized infection ratio (SIR).34
Table 3.
Selected Risk Factors for and Recommendations to Prevent Surgical Site Infection (SSI)
Risk Factor | Recommendation | Quality of Evidence |
---|---|---|
Intrinsic, patient-related (preoperative) | ||
Unmodifiable | ||
Age | No formal recommendation: relationship to increased risk of SSI may be secondary to comorbidities or immunosenescence341-343 | N/A |
History of radiation | No formal recommendation. Prior irradiation at the surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia.183 | N/A |
History of skin and soft-tissue infections | No formal recommendation. History of a prior skin infection may be a marker for inherent differences in host immune function.344 | N/A |
Modifiable | ||
Glucose control | Control serum blood-glucose levels for all surgical patients including patients without diabetes.345 | HIGH |
Obesity | Increase dosing of prophylactic antimicrobial agent for morbidly obese patients.73,346 | HIGH |
Smoking cessation | Encourage smoking cessation within 30 days of procedure.4,347-351 | HIGH |
Immunosuppressive medications | Avoid immune-suppressive medications in perioperative period if possible | LOW |
Hypoalbuminemia | No formal recommendation. Though a noted risk factor,352 do not delay surgery for use of total parenteral nutrition. | N/A |
S. aureus nasal colonization | Decolonize patients with nasal mupirocin or povidine-iodine prior to surgery | MODERATE |
Preparation of patient | ||
Hair removal | Do not remove unless hair will interfere with the operation4; if hair removal is necessary, remove outside of the operating room by clipping. Do not use razors. | HIGH |
Preoperative infections | Identify and treat infections remote to the surgical site (eg, urinary tract infection in the presence of prior to elective surgery.4,353 Do not routinely test or treat for asymptomatic bacteriuria except in urologic procedures.4,353 | MODERATE |
Operative characteristics | ||
Surgical scrub (surgical team members’ hands and forearms) | Use appropriate antiseptic agent to perform preoperative surgical scrub.4,354 For most products, scrub the hands and forearms for 2–5 minutes. | MODERATE |
Skin preparation | Wash and clean skin around incision site. Use a dual agent skin prep containing alcohol unless contraindications exist.4 | HIGH |
Antimicrobial prophylaxis | Administer only when indicated.4 Select appropriate agents based on surgical procedure, most common pathogens causing SSI for a specific procedure, and published recommendations.73 Administer within 1 hour of incision to maximize tissue concentration.73 Discontinue antimicrobial agents after incisional closure in the operating room.a | HIGH |
Blood transfusion | Blood transfusions increase the risk of SSI by decreasing macrophage function. Reduce blood loss and need for blood transfusion to greatest extent possible.355-357 | MODERATE |
Surgeon skill/technique | Handle tissue carefully and eradicate dead space.4 | LOW |
Appropriate gloving | All members of the operative team should double glove and change gloves when perforation is noted.358 | LOW |
Asepsis | Adhere to standard principles of operating room asepsis.4 | LOW |
Operative time | No formal recommendation in most recent guidelines; minimize as much as possible without sacrificing surgical technique and aseptic practice. | HIGH |
Operating room characteristics | ||
Ventilation | Follow American Institute of Architects’ recommendations for proper air handling in the operating room.4,359 | LOW |
Traffic | Minimize operating room traffic.4,207,208 | LOW |
Environmental surfaces | Use an Environmental Protection Agency (EPA)–approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment in accordance with manufacturer’s instructions.4 | LOW |
Sterilization of surgical equipment | Sterilize all surgical equipment according the device manufacturer’s validated parameters: cycle type, time, temperature, pressure, and dry time. Minimize the use of immediate use steam sterilization.4,360 | MODERATE |
Vancomycin and fluoroquinolones can be given 2 hours prior to incision.
Section 2: Background on detection of SSI
Surveillance definitions for SSI
- Surveillance definitions must be established and consistently applied over time to make comparisons within and between institutions meaningful.
- NHSN definitions for SSI are widely used for public reporting, interfacility comparison, and pay-for-performance comparisons,35-38 based on selected procedures identified by procedure codes assigned from the International Classification of Diseases, 10th Revision Clinical Modifications/Procedure Coding System (ICD-10-CM/PCS) and/or current procedural terminology (CPT) codes.35-37
- According to widely used CDC NHSN definitions,43 SSIs are classified as follows (Fig. 1):
- Superficial incisional (involving only skin or subcutaneous tissue of the incision)
- Superficial incisional primary (SIP): SSI identified in a primary incision in a patient with 1 or more incisions.
- Superficial incisional secondary (SIS): SSI identified in the secondary incision in a patient that has had an operation with >1 incision.
- Deep incisional (involving fascia and/or muscular layers)
- Deep-incisional primary (DIP): SSI identified in a primary incision in a patient who has had an operation with 1 or more incisions.
- Deep-incisional secondary (DIS): SSI identified in a secondary incision in a patient who has had an operation with > 1 incision.
- Organ-space: Involving any part of the body opened or manipulated during the procedure, excluding skin incision, fascia, or muscle layers.
Fig. 1.
CDC National Healthcare Safety Network (NHSN) classification for surgical site infection. Modified from Horan TC, et al.362 CDC definitions of nosocomial surgical site infections, 1992.
Surveillance methods for SSI and detection of patients
The most accurate method of SSI surveillance is the direct method for case finding with daily observation of the surgical site by a physician, advanced practice provider, registered nurse, or infection preventionist starting 24–48 hours postoperatively.15,44-46 Although the direct method of case finding has been used as the “gold standard” for some studies, it is rarely used by infection prevention staff due to its high resource utilization requirements and impracticality.
- The indirect method of case finding is less time-consuming than the direct method; it can be performed using criteria or algorithms applied to electronic records; and it can be performed retrospectively.
- The indirect method of case finding consists of 1 or a combination of the following as appropriate based on inpatient or outpatient surveillance and the setting:
- Review of microbiology reports and patient medical records
- Surgeon and/or patient surveys by mail, telephone, or web-based application47
- Patient or family interview, particularly when postoperative care is remote and/or follow-up care is being provided by an alternative provider
- Screening for early or additional postoperative visits, readmission, and/or return to the operating room
- Other information such as coded diagnoses, coded procedures, operative reports, or antimicrobials ordered
- Indirect methods of SSI surveillance have been demonstrated to be reliable (sensitivity, 84%–89%) and specific (specificity, 99.8%) compared to the “gold standard” of direct surveillance.48-50 Components of the indirect methods that were associated with highest sensitivities included review of nursing notes, billing codes, and antimicrobials used.
- Indirect methods for SSI surveillance are less reliable for surveillance of superficial-incisional infections, particularly those occurring after discharge.51
- Automated data systems and electronic health records should be used to improve efficiency, improve sensitivity, and broaden SSI surveillance.50
- SSI surveillance can be expanded by utilizing hospital databases that include administrative claims data (including diagnosis and procedure codes), antimicrobial days, readmission to the hospital, return to the operating room and/or by implementing a system that imports automated microbiologic culture data, surgical procedure data, and general demographic information into a single surveillance database.52-54
- These methods improve the sensitivity of indirect surveillance for detection of SSI and reduce the effort of the infection preventionist.52
- Administrative and automated data used for surveillance purposes should be validated to ensure accuracy.
- Electronic health record (EHR) vendors should increase standardization and automated collection of key metrics. The focus should be to reduce data burden on hospital and health-system staff.
- The proportion of SSIs detected through postdischarge surveillance can vary by surveillance method, operative setting, type of SSI, and surgical procedure.
- The majority of surgical procedures are now outpatient procedures.61 In addition, length of stay following inpatient procedures has decreased. Surveillance methodologies must take these practice changes into account.
- Superficial incisional SSIs are most commonly detected and managed in the outpatient setting. In contrast, deep-incisional and organ-space infections typically require readmission to the hospital for management.51
- CDC is prescriptive about denominator data collection43; however, it is less prescriptive on how possible cases (numerator data) should be identified for evaluation.
- Differences in case finding methodology may lead to variability in surveillance rates.64
- CDC encourages standardization of data sources for more consistent reporting. Both state health departments and the CMS select hospitals for data validation.
Section 3: Background on prevention of SSI
Summary of existing guidelines, recommendations, and requirements
A number of guidelines are available on the prevention of SSIs, and our writing panel compared and contrasted some of the differences in developing our current recommendations.68 We list some of these guidelines below, along with current US reporting requirements.
CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines4,69
American College of Surgeons and Surgical Infection Society SSI Guidelines70
World Health Organization 201871
National Institute for Health and Clinical Excellence (NICE)—United Kingdom 200857,58
SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work Area72
American Society of Health-System Pharmacists (ASHP) Clinical Practice Guideline for Antimicrobial Prophylaxis in Surgery 201373
- Federal requirements
- Centers for Medicare & Medicaid Services (CMS)
- In accordance with the Deficit Reduction Act of 2005, US hospitals that are paid by Medicare under the acute-care inpatient prospective payment system receive their full Medicare Annual Payment Update only if they submit required quality measure information to CMS.
- In addition, US acute-care hospitals submit data to the NHSN for complex SSIs following colon surgery and abdominal hysterectomy. These data are publicly reported on the CMS Hospital Care Compare website77,78 and are used to determine pay-for-performance in both the Hospital-Acquired Condition Reduction Program79 and the Hospital-Value Based Purchasing Program.80
- Accrediting organizations with deeming authority granted by the CMS, such as The Joint Commission and Det Norske Veritas Healthcare (DNV), verify that CMS requirements are met as part of the accreditation process.
Infrastructure requirements
Facilities performing surgery should have the following elements in place:
- Trained infection prevention personnel
- Infection preventionists (1) must be specifically trained in methods of SSI surveillance, (2) must have knowledge of and the ability to prospectively apply the CDC/NHSN definitions for SSIs, (3) must possess basic computer and mathematical skills, and (4) must be adept at providing feedback and education to healthcare personnel (HCP) when appropriate.4,81
- Having an increased number of infection preventionists, certified infection preventionists, and a hospital epidemiologist are associated with lower rates of SSI. A specific threshold for staffing has not been defined.82
- Education for HCP
- A surgeon leader or champion can be a critical partner in changing culture and improving adherence to prevention practices.
- Regularly provide education to surgeons and perioperative personnel through continuing education activities directed at minimizing perioperative SSI risk through implementation of recommended process measures.
- Combine several educational components into concise, efficient, and effective recommendations that are easily understood and remembered.83
- Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all surgeons, anesthesiologists, and perioperative personnel.
Education of patients and families. Provide education for patients and patients’ families to reduce risk associated with intrinsic patient-related SSI risk factors.86,87
- Computer-assisted decision support and automated reminders
- Utilization of automated data
- Install information technology infrastructure to facilitate data transfer, receipt, and organization to aid with tracking of process and outcome measures.
- Consider use of data mining software to identify potential SSIs which can then be further evaluated.
- Consider leveraging existing electronic health record capabilities to provide process measure information that informs improvement approaches.
Section 4: Recommended strategies to prevent SSI
Recommendations are categorized as either (1) essential practices that should be adopted by all acute-care hospitals or (2) additional approaches that can be considered when hospitals have successfully implemented essential practices and seek to further improve outcomes in specific locations and/or patient populations. Essential practices include recommendations in which the potential to affect HAI risk clearly outweighs the potential for undesirable effects. Additional approaches include recommendations in which the intervention is likely to reduce HAI risk but there is concern about the risks for undesirable outcomes, recommendations for which the quality of evidence is low, or recommendations where the evidence supports the effect of the intervention in select settings (e.g., during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially implementing infection prevention approaches listed as essential practices. If HAI surveillance or other risk assessments suggest that there are ongoing opportunities for improvement, hospitals should consider adopting some or all of the infection prevention approaches listed as additional approaches. These approaches can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is given a quality of evidence grade (Table 2).
Essential practices for preventing SSI recommended for all acute-care hospitals
- Administer antimicrobial prophylaxis according to evidence-based standards and guidelines.75 (Quality of evidence: HIGH)
- Begin administration within 1 hour prior to incision to maximize tissue concentration.73,93,94 Administering an antimicrobial agent <1 hour prior to incision is effective; some studies show superior efficacy for administration between 0 and 30 minutes prior to incision compared with administration between 30 and 60 minutes prior to incision.95,96
- Two hours are allowed for the administration of vancomycin and fluoroquinolones due to longer infusion times.
- For cesarean delivery, administer antimicrobial prophylaxis prior to skin incision rather than after cord clamping.97
- In procedures using “bloodless” techniques, many experts believe that antimicrobial agents should be infused prior to tourniquet inflation, though data are lacking to inform this recommendation.98
- Select appropriate antimicrobial agents based on the surgical procedure, the most common pathogens known to cause SSI for the specific procedure, and published recommendations.73
- Although it is not recommended to routinely use vancomycin, this agent should be considered in patients who are known to be MRSA colonized (including those identified on preoperative screening), particularly if the surgery involves prosthetic material.
- Discontinue antimicrobial agents after incisional closure in the operating room.73
- Although some guidelines suggest stopping the antimicrobial agents within 24 hours of surgery, there is no evidence that antimicrobial agents given after incisional closure contribute to reduced SSIs102 even when drains are inserted during the procedure.103 In contrast, antibiotics given after closure contribute to increased antimicrobial resistance104,105 and increased risk of Clostridioides difficile infection106 and acute kidney injury.107
- In a single-center, retrospective, cohort study comparing joint arthroplasty, patients who received a single dose of antibiotic prophylaxis (no additional doses after skin closure) versus 24-hour antibiotic administration, there were no differences in the following outcomes between these 2 groups: prosthetic joint infection, superficial infection, 90-day reoperation, and 90-day complications.108
- Adjust dosing based on patient weight,73 according to the following examples:
- For cefazolin, use 30–40 mg/kg for pediatric patients, use 2 grams for patients weighing ≤120 kg, and 3 grams for patients weighing >120 kg.109,110 Although data are conflicting regarding the role of 3 grams of cefazolin dosing in reducing SSI in obese patients, multiple studies have shown a benefit compared to 2-gram dosing in this patient population,110-112 with few adverse events from a single dose of 3 grams versus 2 grams of cefazolin. Although some hospitals use 1 gram for adult patients weighing ≤80 kg, there is no harm associated with giving a 2-gram dose.
- Dose vancomycin at 15 mg/kg.113
- Dose gentamicin at 5 mg/kg for adult patients and 2.5 mg/kg for pediatric patients. For morbidly obese patients receiving gentamicin, use the ideal weight plus 40% of the excess weight for dose calculation.114
- Re-dose prophylactic antimicrobial agents for lengthy procedures and in cases with excessive blood loss during the procedure (ie, >1,500 mL).73 Re-dose prophylactic antimicrobial agents at intervals of 2 half-lives (measured from the time the preoperative dose was administered) in cases that exceed this period. For example, re-dose cefazolin after 4 hours in procedures >4 hours long.73
- Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI.115,116 (Quality of evidence: HIGH)
- A 2019 meta-analysis of 40 studies (28 randomized clinical trials [RCTs] and 12 observational studies) found that the combination of parenteral and oral antimicrobial prophylaxis and mechanical bowel preparation prior to elective colorectal surgery significantly reduces SSI, postoperative ileus, anastomotic leak, and 30-day mortality, without an increase in C. difficile infection.116 In 2021,117 the meta-analysis was updated to include the results from the MOBILE and ORALEV trials, which further demonstrated the decreases shown in 2019,119,120 along with data showing that oral antimicrobial prophylaxis alone without mechanical bowel preparation significantly reduces SSI, anastomotic leak, and 30-day mortality.121,122 We continue to recommend the combination of parenteral and oral antimicrobial prophylaxis and mechanical bowel preparation prior to elective colorectal surgery, unless there is a contraindication to mechanical bowel preparation, in which case, only parenteral and oral antimicrobial prophylaxis should be administered.
- Use of combination parenteral and oral antimicrobial agents to reduce the risk of SSI should be considered in any surgical procedure where entry into the colon is possible or likely, as in gynecologic oncology surgery.
- Mechanical bowel preparation without use of oral antimicrobial agents does not decrease the risk of SSI.115 A recent prospective randomized multicenter trial confirmed earlier meta-analysis findings, with significantly higher SSI and anastomotic leakage in patients who received mechanical bowel preparation without oral antimicrobial agents.122
- Decolonize surgical patients with an antistaphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (Quality of evidence: HIGH). Decolonize surgical patients for other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (Quality of evidence: LOW)
- Decolonization refers to the practice of treating patients with an antimicrobial and/or antiseptic agent to suppress S. aureus colonization inclusive of both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA).
- Published data are most supportive of using intranasal mupirocin and chlorhexidine bathing. There are some preliminary data on intranasal povidone-iodine administered immediately before surgery. This approach may have practical advantages, but more data are needed.124 Fewer data exist for other alternative strategies such as intranasal alcohol-based antisepsis and phototherapy.
- The strongest data recommend up to 5 days of intranasal mupirocin (twice daily) and bathing with chlorhexidine gluconate (CHG) (daily).
- A meta-analysis of 17 studies of patients undergoing cardiac or orthopedic procedures concluded that decolonization strategies prevent S. aureus SSIs.125
- Some trials demonstrated that preoperative screening for S. aureus, combined with intranasal mupirocin and CHG bathing, was effective in reducing SSI.
- For example, a randomized, double-blind, placebo-controlled, multicenter trial showed that rapid identification of S. aureus nasal carriers, followed by decolonization with intranasal mupirocin and CHG bathing was associated with a >2-fold reduction in the risk for postoperative infection due to S. aureus and an almost five-fold reduction in incidence of deep-incisional SSI due to S. aureus.126 Patients undergoing clean procedures (eg, cardiothoracic, orthopedic, vascular) who were randomized to decolonization also had reduced 1-year mortality compared with those patients who were randomized to the placebo.127
- A 20-hospital, nonrandomized, quasi-experimental study of patients undergoing cardiac surgery or total joint arthroplasty found a significant decrease in deep-incisional or organ-space S. aureus SSI after implementing a bundle of interventions, including S. aureus nasal screening, decolonization of nasal carriers with mupirocin, CHG bathing for all patients, and perioperative antibiotic prophylaxis adjustment based on MRSA carriage status.128
- Some hospitals continue to use screen-and-treat strategies because the results from screening for MRSA colonization can guide antibiotic prophylaxis.
- In contrast, other trials that assessed a wide range of surgical specialties did not observe a protective effect against SSIs.
- A prospective, interventional, cohort study with crossover design involving 21,000 patients concluded that universal, rapid screening for MRSA at admission combined with decolonization of carriers did not reduce the SSI rate due to MRSA.131 This study included 8 surgical specialties: abdominal surgery, orthopedics, urology, neurosurgery, cardiovascular surgery, thoracic surgery, plastic surgery, and solid-organ transplantation. Similarly, a prospective interventional cohort study of 10 hospitals did not find a decrease in MRSA clinical cultures when MRSA screening and decolonization were performed among 9 surgical specialties. However, when the analysis was limited to patients undergoing clean surgery, MRSA screening and decolonization was significantly associated with reductions in MRSA SSI rates.132,133 Clean surgery included cardiothoracic, neuro, orthopedic, plastic, and vascular surgery.
- A double-blinded, randomized-controlled trial involving >4,000 patients undergoing general, gynecologic, neurologic, or cardiothoracic surgery showed that universal intranasal mupirocin application, when not combined with CHG bathing, did not significantly reduce the S. aureus SSI rate.134 In a secondary analysis of this data, the use of intranasal mupirocin was associated with an overall decreased rate of nosocomial S. aureus infections among the S. aureus carriers.
- A Cochrane review concluded that mupirocin decolonization of the nares alone may be effective, particularly in certain groups, including patients undergoing orthopedic and cardiothoracic procedures.135 However, routine preoperative decolonization with mupirocin without screening may lead to mupirocin resistance.136
- Routine decolonization with antiseptic agents such as intranasal povidone-iodine without screening can be performed because povidone-iodine resistance has not been observed.
- One single-center RCT comparing intranasal povidone-iodine with mupirocin in total joint arthroplasty and spinal surgery patients found that povidone-iodine and mupirocin were similarly effective.137 In that RCT, topical CHG wipes in combination with povidone-iodine was given within 2 hours of surgery versus with mupirocin during the 5 days before surgery.137 There was no significant difference between deep SSI rates when comparing those who received povidone-iodine with those who received mupirocin.
- Two quasi-experimental, single-center studies of intranasal povidone-iodine decolonization reported a significant reduction in SSIs when compared with standard care among preintervention groups. One study paired intranasal povidone-iodine decolonization with CHG wipes and oral povidone-iodine rinse for elective orthopedic surgery138; the other study paired it with CHG wipes or baths and povidone-iodine skin antisepsis for urgent lower extremity repairs of fractures that required hardware.139
- Data are mixed on at-home preoperative bathing with CHG-containing products alone for patients not known to be colonized with Staphylococcus aureus.
- Preoperative bathing with agents such as CHG has been shown to reduce bacterial colonization of the skin.140,141 Several studies have examined the utility of preoperative showers, but none has definitively proven that they decrease SSI risk. A Cochrane review evaluated the evidence for preoperative bathing or showering with antiseptics for SSI prevention.142 Six RCTs evaluating 4% CHG use were included in the analysis, with no clear evidence of benefit noted. Several of these studies had methodologic limitations and were conducted several years ago. Thus, the role of preoperative bathing in SSI prevention remains uncertain.
- To achieve the maximum antiseptic effect of CHG, adequate levels of CHG must be achieved and maintained on the skin. Typically, adequate levels are achieved by allowing CHG to dry completely. Additional strategies for preoperative bathing with CHG, such as preimpregnated cloths, have shown promise,143-145 but data are currently insufficient to support this approach.
- Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (Quality of evidence: MODERATE)
- Use of povidone-iodine or CHG-based vaginal preparation agents immediately before cesarean delivery reduces endometritis by 59%, with possibly even greater benefit among women in labor.146 Products should be chosen and used in accordance with manufacturer’s instructions for use.
- Vaginal preparation with antiseptic solution is also recommended for elective hysterectomy.147
- Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure.4,119 (Quality of evidence: MODERATE)
- If hair removal is necessary in elective procedures, remove hair outside the operating room using clippers or a depilatory agent.
- Razors may be acceptable for hair removal in a subset of procedures (eg, procedures involving male genitalia). One small, single-center, RCT demonstrated that clipping hair on the scrotum can cause more skin trauma than razors; clipping hair did not decrease the rate of SSI.148
- Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (Quality of evidence: HIGH)
- Alcohol is highly bactericidal and effective for preoperative skin antisepsis, but it does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with CHG or an iodophor.149 Alcohol is contraindicated for certain procedures due to fire risk, including procedures in which the preparatory agent may pool or not dry (eg, involving hair). Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
- The most effective antiseptic to combine with alcohol remains unclear; however, data from recent trials favor the use of CHG–alcohol over povidone-iodine–alcohol.
- A Cochrane review of 13 studies, published in 2015, was inconclusive regarding the best strategy for preoperative skin antisepsis.150 Only 1 of these studies compared 0.5% CHG–alcohol to povidone-iodine–alcohol.
- Four RCTs (3 single center and 1 multicenter) have compared CHG–alcohol to povidone-iodine–alcohol.
- Tuuli et al151 conducted a single-center RCT of 1,147 women undergoing cesarean delivery. Women randomized to receive CHG–alcohol had a 45% reduction in SSI compared to women randomized to receive povidone-iodine–alcohol (relative risk, 0.55; 95% confidence interval, 0.34–0.90; P = .02).
- Ritter et al152 conducted a single-center RCT of 279 patients undergoing lower-limb procedures. Patients randomized to receive povidone-iodine–alcohol had a 3.5-fold higher rate of wound healing complications, including SSI, compared with patients randomized to receive CHG-alcohol.
- Broach et al153 conducted a single-center, noninferiority RCT of 802 patients undergoing elective, clean-contaminated colorectal procedures. The SSI rate was higher among patients randomized to receive povidone-iodine–alcohol (18.7% vs 15.9%), which failed to meet criterion for noninferiority compared to CHG–alcohol.
- Charehbili et al154 conducted a multicenter, cluster-randomized trial with crossover among 3,665 patients undergoing breast, vascular, colorectal, gallbladder, or orthopedic procedures. No difference in SSI rates was observed between the 2 groups, but some concerns were raised about the methods, including cluster sample size, number of clusters, and how the treatment period was analyzed.155
- CHG–alcohol is the antiseptic of choice for patients with S. aureus colonization.128
- Antiseptics are not interchangeable. Follow manufacturer’s instructions to ensure correct application. Topical CHG preparations may be contraindicated for use in mouth, eyes and ears, patients with skin disease involving more than the superficial layers of skin, and procedures involving the meninges. Use of topical CHG preparations for preterm infants is controversial due to concerns for skin toxicity, absorption, and resultant toxicity including neurotoxicity.158 However, apart from these specific contraindications, topical CHG for skin antisepsis and SSI prevention has been shown to be safe.158-162
- For procedures not requiring hypothermia, maintain normothermia (temperature >35.5°C) during the perioperative period. (Quality of evidence: HIGH)
- Even mild hypothermia can increase SSI rates. Hypothermia may directly impair neutrophil function or impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia. Hypothermia may increase blood loss, leading to wound hematomas or the need for transfusion—both of which can increase SSI rates.163
- Patients who are hypothermic at the end of surgery may remain hypothermic for up to 5 hours. Although there is not a standardized duration of postoperative warming, one study used 2 hours of postoperative warming and showed reduced rates of SSI.
- Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (Quality of evidence: HIGH)
- A wound protector, a plastic sheath that lines a wound, facilitates retraction of an incision during surgery without the need for additional mechanical retractors.
- A recent meta-analysis of 14 randomized clinical trials in 2,689 patients reported that the use of a plastic wound protector was associated with a 30% decrease in risk of SSI.169
- There was a significant trend toward greater protective effect using a dual ring protector as compared to a single ring protector: 29% decrease in risk of SSI for dual ring and 16% decrease in risk of SSI for single ring.169
- Another prospective randomized study of dual ring protectors in pancreatectomy showed a reduction in SSI rate from 44% to 21% (P = .011) with the use of a dual ring protector.170
- Perform intraoperative antiseptic wound lavage.171 (Quality of evidence: MODERATE)
- Wound lavage is a common practice, although the solution and volume used for lavage differs among surgeons.
- Several systematic reviews and meta-analyses support the use of prophylactic intraoperative wound irrigation with sterile dilute povidone-iodine lavage to decrease the risk of SSIs. One systematic review and meta-analysis published in 2017 evaluated 21 RCTs and concluded that lavage with sterile dilute povidone-iodine decreased the risk of SSI compared to nonantiseptic lavage (odds ratio [OR], 0.31; 95% confidence interval [Cl], 0.13–0.73).102,173 This study reported no benefit from antibiotic irrigation and discouraged this practice.
- A systematic review and network meta-analysis published in 2021 reported that relative to saline lavage, both antibiotic irrigation (OR, 0.439; 95% CI, 0.282–0.667) and sterile dilute povidone-iodine (OR, 0.573; 95% CI, 0.321–0.953) decreased the risk of SSI. A third systematic review and meta-analysis published in 2015 reported a similar benefit of antibiotic irrigation and sterile dilute povidone-iodine in the subgroup analysis focused on colorectal surgery.174,175 Data were mixed in a different meta-analysis published in 2019,176 potentially due to whether the antibiotic lavage (typically a β-lactam or aminoglycoside agent) was used in clean–clean-contaminated or contaminated–dirty wounds.
- We recommend the use of dilute povidone-iodine lavage over saline lavage, making sure that sterility is maintained during preparation and administration to enhance patient safety. We recommend studying antibiotic irrigation versus dilute povidone-iodine irrigation in an RCT focused on intra-abdominal surgery that is contaminated–dirty.
- Given the dearth of povidone-iodine solutions formally labeled “sterile,” we advise surgeons to educate themselves as to their options and to carefully weigh the risks and benefits of using povidone-iodine solutions available at their facility.
- Bacitracin is contraindicated. The FDA withdrew injectable bacitracin from the market because safety concerns outweighed the benefits. This was based on case reports of intraoperative anaphylactic shock associated with bacitracin irrigation.177
- Control blood-glucose level during the immediate postoperative period for all patients.94 (Quality of evidence: HIGH)
- Monitor and maintain postoperative blood-glucose level regardless of diabetes status.
- Maintain postoperative blood-glucose level between 110 and 150 mg/dL. Increased glucose levels during the operational procedure are associated with higher levels in the postoperative setting.180 Studies on postoperative blood glucose have focused on monitoring through postoperative day 1–2; however, heterogeneity between studies makes it impossible to recommend a definitive window for postoperative blood-glucose control other than 24–48 hours.94,180-185
- The ideal method for maintaining target postoperative blood-glucose level remains unknown. Generally, continuous insulin-infusion protocols lead to better control than subcutaneous insulin (sliding scale) strategies.186 Continuous insulin infusion commonly requires intensive monitoring; thus, its use in the ambulatory surgery is often not feasible.
- Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (Quality of evidence: HIGH)
- The World Health Organization (WHO) checklist is a 19-item surgical safety checklist to improve adherence with best practices.189
- A multicenter, quasi-experimental study conducted across 8 countries demonstrated that use of the WHO checklist led to lower surgical complication rates, including SSI and death.190
- Perform surveillance for SSI. (Quality of evidence: MODERATE)
- Identify high-risk, high-volume operative procedures to be targeted for SSI surveillance based on a risk assessment of patient populations, operative procedures performed, and available SSI surveillance data. Some surveillance is also mandated by federal and state regulations.
- Identify, collect, store, and analyze data needed for the surveillance program.4
- Develop a database for storing, managing, and accessing data collected on SSIs.
- Implement a system for collecting data needed to identify and report SSIs. This is discussed in Section 2. Consider collecting data on patient comorbidities (including American Society of Anesthesiology [ASA] score and specific risk factors such as body mass index and diabetes), surgical factors (including wound class, operative duration), process measures (including completion of essential practices discussed in this section), and specifics of SSI (including depth, infecting organism, and antimicrobial susceptibilities).
- Develop a system for routine review and interpretation of SSI rates and/or SIRs to detect significant increases or outbreaks and to identify areas where additional resources might be needed to improve SSI rates.34,194 If increased rates are identified, determine the number of infections that were potentially preventable.195
- Convene key national agencies, organizations, and societies to evaluate. Where possible, align definitions and reporting requirements.
- Increase the efficiency of surveillance by utilizing automated data. (Quality of evidence: MODERATE)
- Implement a method to electronically transmit data to infection prevention and control personnel needed to determine denominator data and calculate SSI rates for various procedures. This might include procedure data, process measure data, readmission and rehospitalization data, postoperative antimicrobial data, microbiology data, and diagnosis and procedure codes.54,196-199
- Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (Quality of evidence: MODERATE)
- Routinely audit and provide confidential feedback on SSI rates or SIRs and adherence to process measures to individual surgeons, the surgical division and/or department chiefs, and hospital leadership.4,200
- Provide risk-adjusted SSI SIRs for each type of procedure under surveillance and reported to the NHSN. For procedures not reported to the NHSN, there may be alternative data to review through surveillance programs such as National Surgical Quality Improvement Program (NSQIP).201
- Anonymously benchmark procedure-specific, risk-adjusted SSI SIRs among peer surgeons.
- Educate surgeons and perioperative personnel about SSI prevention measures. (Quality of evidence: LOW)
- Include risk factors, outcomes associated with SSI, local epidemiology (eg, SSI rates by procedure, rate of methicillin-resistant Staphylococcus aureus [MRSA] infection in a facility), and essential prevention measures.
- Educate patients and their families about SSI prevention as appropriate. (Quality of evidence: LOW)
- Provide instructions and information to patients prior to surgery describing strategies for reducing SSI risk. Specifically provide preprinted materials to patients.202
- Examples of printed materials for patients are available from the following web pages:
- Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and medical device manufacturer instructions for use.4,94 (Quality of evidence: MODERATE)
- Implement policies and practices to reduce modifiable risk factors (Table 1), including the following:
- Optimally disinfect the hands of the surgical team members.
- Adhere to hand hygiene practices, including nonsurgeon members of the operating team.206
- Properly care for and maintain the operating rooms, including appropriate air handling, pressure relative to hallway, temperature, humidity, and optimal cleaning and disinfection of equipment and the environment.4
- Maintain asepsis from the start of preparation of surgical instruments on the sterile field through wound closure and dressing.
- Establish a robust infection control risk assessment program focused on mitigating risk during construction projects.
- Proactively address potential risks from supply-chain shortages and communicate to frontline teams.
- Discuss any staffing shortages and potential impact on outcomes as they relate to compliance with SSI prevention measures.
- Observe and review operating-room personnel and the environment of care in the operating room and in central sterile reprocessing. (Quality of evidence: LOW)
- Perform direct observation audits of operating-room personnel to assess operating-room processes and practices to identify infection control lapses, including but not limited to adherence to process measures (antimicrobial prophylaxis choice, timing and duration protocols, hair removal, etc), surgical hand antisepsis, patient skin preparation, operative technique, surgical attire (wearing and/or laundering outside the operating room), and level of operating-room traffic.211-215 Perform remediation when breaches of standards are identified.
- Operating-room personnel should include surgeons, surgical technologists, anesthesiologists, circulating nurses, residents, medical students, trainees, and device manufacturer representatives.211
- Perform direct observation audits of environmental cleaning practices in the operating room, instrument reprocessing (sterilization) area, and storage facilities.
- Review instrument reprocessing and flash sterilization or immediate-use steam sterilization (IUSS) logs.
- Review maintenance records for operating room heating, ventilation, and air conditioning (HVAC) system including, results of temperature, relative humidify, and positive air pressure maintenance testing in the operating rooms(s).
- Provide feedback and review infection control measures with operating-room and environmental personnel.
Additional approaches for preventing SSI
These additional approaches can be considered when hospitals have successfully implemented essential practices and seek to further improve outcomes in specific locations and/or patient populations.
- Perform an SSI risk assessment. (Qualify of Evidence: LOW)
- Convene a multidisciplinary team (eg, surgical leadership, hospital administration, qualify management services, and infection control) to identify gaps, improve performance, measure compliance, assess impacts of interventions, and provide feedback.216
- Consider use of negative-pressure dressings in patients who may benefit. (Quality of Evidence: MODERATE)
- Guidance is lacking regarding which patients most benefit from the use of negative-pres sure dressings, with some evidence that the benefit increases with age and body mass index.225
- It is important to assess the ability of the patient to manage a negative-pressure dressing, particularly if used in the ambulatory setting.
- Cost-effectiveness studies of negative-pressure dressings are needed.
- Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit, and/or surgical ward. (Quality of evidence: MODERATE)
- Perform direct observation audits of hand-hygiene practices among all HCP with direct patient contact.213
- Evaluate wound care practices.227
- Perform direct observation audits of environmental cleaning practices.
- Provide feedback and review infection control measures with HCP in these perioperative care settings.
- Use antiseptic-impregnated sutures as a strategy to prevent SSI. (Quality of evidence: MODERATE)
- Human volunteer studies involving foreign bodies have demonstrated that the presence of surgical sutures decreases the inoculum required to cause an SSI from 106 to 102 organisms.228
- Some trials have shown that surgical wound closure with triclosan-coated polyglactin 910 antimicrobial sutures may decrease the risk of SSI compared to standard sutures.229,230 For example, an RCT of 410 colorectal surgeries concluded that the rate of SSI decreased >50% among patients who received antimicrobial sutures (9.3% in control group vs 4.3 among cases; P = .05).231
- In contrast, a systematic review and meta-analysis evaluated 7 RCTs and concluded that neither SSI rates (OR, 0.77; 95% CI, 0.4–1.51; P = .45) nor wound dehiscence rates (OR, 1.07; 95% CI, 0.21–5.43; P = .93) were statistically different compared to controls.232 In addition, a small study raised concern about higher wound dehiscence rates associated with using these antimicrobial sutures.233
- The impact of routinely using antiseptic-impregnated sutures on the development of antiseptic resistance remains unknown.
Approaches that should not be considered a routine part of SSI prevention
- Do not routinely use vancomycin for antimicrobial prophylaxis.73 (Quality of evidence: MODERATE)
- Vancomycin should not routinely be used for antimicrobial prophylaxis, but it can be an appropriate agent for specific scenarios.128,234 Reserve vancomycin for specific clinical circumstances, as in patients who are known to be MRSA colonized (including those identified on preoperative screening), particularly if the surgery involves prosthetic material. Vancomycin can also be used in the setting of a proven outbreak of SSIs due to MRSA.235
- Suspected high rates of MRSA SSI should not be used as justification for vancomycin use. In a cohort study of 79,092 surgical procedures, the primary reason for vancomycin perioperative prophylaxis was the perception of high facility rates of MRSA or high-risk procedure for MRSA. Patients who received vancomycin prophylaxis because of the perceived high facility risk of MRSA had no increase in prevalence of MRSA colonization compared with the general surgical population. The incidence of SSIs was the same regardless of vancomycin prophylaxis, but the incidence of acute kidney injury (AKI) was significantly higher among patients who received vancomycin.236
- In a retrospective cohort study of 79,058 surgical procedures, vancomycin perioperative prophylaxis was inde-pendently associated with significantly increased risk of AKI.107
- Vancomycin does not have activity against gram-negative pathogens and appears to have less activity against MSSA than β-lactam agents. The addition of vancomycin to standard antimicrobial prophylaxis has been done in specific circumstances, but the benefits should be weighed against the risks.73,237-239
- In a cohort study of 70,101 surgical cases, vancomycin plus β-lactam combination prophylaxis was associated with a greater risk of AKI compared with vancomycin alone.241 In that study, vancomycin plus a β-lactam reduced the incidence of SSIs following cardiothoracic procedures compared with either antibiotic alone. However, this antimicrobial combination did not reduce SSIs for orthopedic, vascular, hysterectomy, or colorectal procedures.
- Do not routinely delay surgery to provide parenteral nutrition. (Quality of evidence: HIGH)
- Individual trials comparing enteral and parenteral perioperative nutrition and comparing immunomodulating diets containing arginine and/or glutamine to standard control diets tend to have very small sample sizes and fail to show significant differences in SSI rates. In 2 recent meta-analyses, however, postoperative infectious complications were reduced in patients receiving enteral diets containing glutamine and/or arginine administered either before or after the surgical procedure.244,245
- Do not routinely use antiseptic drapes as a strategy to prevent SSI. (Quality of evidence: HIGH)
- An incise drape is an adhesive film that covers the surgical incision site to minimize bacterial wound contamination from endogenous flora. These drapes can be impregnated with antiseptic chemicals such as iodophors.
- A nonrandomized retrospective study similarly concluded that impregnated drapes do not prevent SSI after hernia repair.249
Unresolved issues
- Optimize tissue oxygenation at the incision site.
- In a meta-analysis of 5 studies, perioperative supplemental oxygen administration led to a relative SSI risk reduction of 25%. In contrast, a more recent meta-analysis of 15 studies was inconclusive.250 Additional studies published since the 2014 SHEA Compendium have similarly not shown a reduction in SSI in patients who received supplemental oxygen at a fraction of inspired oxygen (FiO2) of 80%.251-253
- Most trials compared 80% FiO2 to 20%–35% FiO2. The benefit of other oxygen concentrations remains unknown.
- Supplemental oxygen is most effective when combined with additional strategies to improve tissue oxygenation including maintenance of normothermia and appropriate volume replacement. Tissue oxygenation at the incision site depends on vasoconstriction, temperature, blood supply, and cardiac output.
- Preoperative intranasal and pharyngeal CHG treatment for patients undergoing cardiothoracic procedures
- Although data from an RCT trial support the use of CHG nasal cream combined with 0.12% CHG mouthwash,257 CHG nasal cream is neither FDA approved nor commercially available in the United States.
- Use of gentamicin-collagen sponges
- Gentamicin-collagen sponges have been evaluated as an intervention to decrease SSI among colorectal and cardiac surgical patients.
- Cardiothoracic surgical patients. Four RCTs have evaluated the use of gentamicin-collagen sponges in cardiothoracic surgery. Three of these trials demonstrated a decrease in SSIs and one demonstrated no difference.263-266 A recent meta-analysis combining these trials and 10 observational studies concluded that the risk of deep sternal wound infection was significantly lower in patients who received a gentamicin-collagen sponge than patients who did not (RR, 0.61; 95% CI, 0.39–0.98) despite significant heterogeneity among the trials.267
- Gentamicin-collagen sponges are not currently FDA approved for use in the United States.
- Use of antimicrobial powder
- Multiple publications have examined the use of vancomycin powder in surgical incisions, especially for spinal and cranial procedures for which S. aureus is a primary pathogen.268,269 Although a few reviews report a lower rate of SSI in spinal surgery with the use of vancomycin powder,270 other references report a significant increase in the proportion of SSI with polymicrobial and gram-negative pathogens when they occur.271-273 In addition, a prospective randomized trial comparing the use of vancomycin powder in combination with intravenous vancomycin to the use of intravenous vancomycin alone found no benefit with the addition of vancomycin powder.274
- Use of surgical attire
- Although there are longstanding traditions and opinions regarding surgical attire in the operating room, no strong evidence exists for many of them. It has not been demonstrated that surgical attire affects SSI rates.275 One approach to managing issues pertaining to surgical attire is to form a multidisciplinary body including infection control, surgery, nursing, and anesthesia to discuss and agree to some sensible, not overly aggressive or cumbersome attire standards, and to establish policies and procedures that are compliant with state and CMS requirements.275
Section 5: Performance measures
Internal reporting
These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for SSI (Table 4).
Table 4.
SSI Prevention Internal Reporting Process and Outcome Measures
Internal Reporting Process Measure Example: Compliance with Antimicrobial Prophylaxis Guidelines |
---|
Percentage of procedures in which antimicrobial prophylaxis was provided appropriately = (No. of patients who appropriately received antimicrobial prophylaxis/Total number of selected operations performed) ×100 1. Correct antibiotic for specific surgery 2. Correct antibiotic dose 3. Administrative start time within 1 hour of incision (2 hours allowed for vancomycin and fluroquinolones) 4. Discontinuation of agent after skin closure |
Internal Reporting Outcome Measure Example: Surgical Site Infection Standardized Infection Ratio (SIR) |
SIR = Ratio of observed number of SSIs (O)/Predicted number of SSIs (P) for a specific type of procedure278 |
Process measures
EXAMPLE: Compliance with antimicrobial prophylaxis guidelines
- Measure the percentage of procedures in which antimicrobial prophylaxis was provided appropriately. Appropriateness includes (1) correct antibiotic for specific surgery, (2) correct antibiotic dose, (3) administration start time within 1 hour of incision (2 hours allowed for vancomycin and fluoroquinolones), and (4) discontinuation of the agent after skin closure.
- Numerator: Number of patients who appropriately received antimicrobial prophylaxis.
- Denominator: Total number of selected operations performed.
- Multiply by 100 so that measure is expressed as a percentage.
Outcome measures
EXAMPLE: Surgical site infection SIR
- Use NHSN definitions and risk adjustment methods for measuring SSI incidence43
- SIR numerator: Number of surgical site infections following a specified type of procedure.
- SIR denominator: Total number of predicted SSIs following a specified type of procedure. The SIR denominator is calculated in NHSN using national baseline data and is risk adjusted for several facility, patient, and procedure-level factors.34
- SIR is the ratio of the observed (O) number of SSIs that occurred compared to the predicted (P) number for a specific type of procedure: SIR = O/P.34 Values that exceed 1.0 indicate that more SSIs occurred than expected. Importantly, SIR can only be calculated if the number of predicted HAIs is ≥1. Thus, this approach maybe more difficult for small surgical programs or if few procedures are performed for any 1 procedure type.276
External reporting
There are many challenges in providing useful information to consumers and other working partners while preventing unintended consequences of public reporting of HAIs.283-285 Recommendations and requirements for public reporting of HAIs have been provided by HICPAC,286,287 the National Quality Forum,288 and the CMS289 (Table 5).
Table 5.
SSI Prevention External Reporting Outcome Measures
Federal requirementsa |
---|
1. Reported via CDC NHSN in the CMS Hospital Inpatient Quality Reporting program.289 2. Since 2012, SSI data reporting for inpatient abdominal hysterectomy and inpatient colon procedures has been required.290,291 3. Hospitals in states with a SSI reporting mandate must abide by their state’s requirements, even if they are more extensive than federal requirements. |
State requirements and collaboratives |
1. In states with mandatory SSI reporting requirements, hospitals must collect and report the data required by the state. 2. Hospitals should check with the state or local health department for requirements. |
Note. CDC, Centers for Disease Control and Prevention; NHSN, National Health Safety Network. CMS, Centers for Medicare & Medicaid Services; HICPAC, Healthcare Infection Control Practices Advisory Committee.
Outcome measures
External reporting measures now focus mostly on outcomes.
Since 2012, the CMS has imposed a reporting requirement for SSI data for inpatient abdominal hysterectomy and inpatient colon procedures.290,291
- Federal and state requirements
- Federal requirements
- CMS published a final rule in the Federal Register on August 18, 2011 that includes surgical site infection (SSI) reporting via the NHSN in the CMS Hospital Inpatient Quality Reporting (IQR) Program requirements for 2012.289 More specifically, the rule announced a reporting requirement for SSI data for inpatient abdominal hysterectomy and inpatient colon procedures.291
- The requirements for SSI reporting to the NHSN for the hospital IQR program do not preempt or supersede state mandates for SSI reporting to NHSN (ie, hospitals in states with a SSI reporting mandate must abide by their state’s requirements, even if they are more extensive than the requirements for this CMS program). NHSN users reporting SSI data to the system must adhere to the definitions and reporting requirements for SSIs as specified in the NHSN Patient Safety Component Protocol Manual.43,291
- State requirements. Hospitals in states that have mandatory SSI reporting requirements must collect and report the data required by the state. For information on state requirements, check with your state or local health department.
External quality initiatives
Several external quality initiatives focused on SSI prevention are ongoing. The benefits from participation in these external quality initiatives are unknown but may include improvement in the culture of safety and patient outcomes, including decreased rates of SSI.292
Section 6: Implementation of SSI prevention strategies
SSI prevention science and education must be partnered with purposeful implementation of interventions to achieve desired outcomes. Beyond protocol development and educational efforts, this includes measurement of adherence to agreed-upon practices, understanding and addressing potential barriers to adherence, and frequent feedback to all partners.
Reliability is the frequency at which an intervention is completed when indicated. Implementation of any practice requires monitoring for reliability, commonly known as a process measure. In SSIs, process measurement is especially important to successful implementation due to the complexity of systems involved and of the outcome itself. Connecting a reduction or increase in SSI rates to utilization of a bundle is difficult without reliability measurement, and protocol adherence has been directly correlated to improved outcomes.293 Successful implementation efforts described in the literature have frequently failed to identify a single effective intervention, instead emphasizing the effect of process reliability.294-296
High reliability can be achieved through different methods and conceptual frameworks. The following outline summarizes ways in which facilities have achieved reliability. Choice of a method for a given group depends on system context,297,298 local knowledge of improvement and implementation science, and resources available to support the effort.
- Quality improvement tools
- Team projects. Implementation often occurs in the context of a team project, such as that used to teach and disseminate quality improvement methods. Utilizing a planned quality improvement project may be a good approach for initial implementation of an existing or novel bundled intervention.299-302 Because SSIs may present weeks to months after surgery and because new systems need time to adjust, SSI prevention implementation may take longer than the typical 90–120 days of a quality improvement project and may benefit from an iterative and adaptive approach over time.303
- Process mapping. Understanding the system involved may help in planning more effective interventions, particularly in resource-constrained settings.304
- Reliability measurement. Process reliability should be measured regularly. SSI prevention process measures like antibiotic choice or timing of administration of preoperative antibiotics may be measurable using existing data available in an electronic health record.305 Other behaviors, such as environmental cleaning practices, may require direct observation.306
- Apparent cause analysis. Learning from failed processes or unwanted outcomes is a useful means to gain a shared mental model and advance efforts. Objective review of data helps avoid assigning blame to individuals and focusing on needed system improvements.
- Surveillance and improvement networks. Networks of institutions within the US and internationally have arisen to collect data, learn collectively, and improve patient outcomes.312,313 Groups such as Solutions for Patient Safety,314 the NSQIP,315 and statewide collaboratives316 have helped facilitate improvement through direct engagement or supplying data to drive interventions. Punitive approaches have been less effective at affecting improvement.283
- Multidisciplinary approach (Table 6)
- Efforts to prevent SSIs should consider the large variety of touch points, risk factors, and partners needed to implement multiple effective strategies.31,295,296,317-319 Partners from all areas should be included in the prevention effort, such as preoperative clinic staff, perioperative staff, staff in sterile processing, postoperative staff, pharmacists, etc.
- Frontline involvement. SSI prevention is not the sole responsibility of surgeons and involves mitigating risk inside and outside operating rooms. Recruiting nonsurgeon groups, such as medical or nursing trainees or pharmacists320 to lead improvement efforts, has been shown to be effective.
- Education and reinforcement. Orienting patients, families, and care providers to the need to prevent SSI by implementing interventions pre-, intra-, and postoperatively is crucial. Emphasizing interventions that they can control has been effective at reducing SSIs.31,202,321-324 Education should be provided to patients and families in their primary languages.
- Human factors engineering
- Interventions that automate reminders (eg, alarms to prevent excessive door opening or electronic alerts to re-dose antibiotics)325,326 or processes themselves may be effective at preventing SSIs.325,327 Existing information systems, such as electronic health records, can be leveraged for this purpose as well as for standardizing evidence-based order sets.
- Operating-room door openings are a surrogate marker for poor operating-room discipline.208,327,329 Agreeing on a limit for how many door openings during surgery are acceptable and staying below that limit have been associated with decreased incidence of SSIs.328 Communication between the surgeon and operating-room staff on the equipment needed prior to surgery can lead to fewer door openings.328 Operating-room personnel turnover during procedures has been associated with an increased risk of SSI, even after statistically adjusting for length of surgery.330 When possible, shift changes and breaks should wait until the procedure has ended.
- Interventions to prevent SSIs can be optimized by identifying the people (eg, preoperative nurse, operating room nurse, surgeon, patient, or family) needed to successfully implement the intervention and provide them with directed tools to support adherence with the intervention. The perspectives of each of these partners need to be considered to identify barriers and facilitators to intervention adherence.334
- Accountability
- Accountability is an essential principle for preventing HAIs by ensuring evidence-based implementation strategies are used consistently, maximizing their effectiveness in preventing HAIs.
- Interventions, bundle components, and practices should be evidence-based as much as possible338 and should be deemed appropriate for the surgical population (eg, evidence from the adult population may not be appropriate to apply in a pediatric population).
- Safety culture and practices
- SSI prevention efforts align well with, and may be contextualized within, patient and employee safety campaigns. However, culture change is a prolonged and ongoing process. SSI prevention should not be delayed until safety culture is improved, but rather used as a concrete example of the benefits of safe behaviors.
Table 6.
Fundamental Elements of Accountability and Engagement for SSI Prevention
Organizational Role | Responsibilities | Accountability |
---|---|---|
Senior management (executives, senior directors) (Note: regulatory requirement for US hospitals) | Ensure sufficient funds, expertise, and commitment to an infection prevention and control (IPC) program that effectively prevents healthcare-associated infections (HAIs) and the transmission of epidemiologically important pathogens. | Accountable for proper resource allocation and evaluation, including training, competency, and ancillary support (eg, data analysis). |
Surgical services leadership (surgeon, anesthesia, perioperative nursing leaders) | Ensure all perioperative staff are aware of their roles and expectations as they relate to SSI prevention. Advocate for the support of senior leadership. | Direct evaluation of groups and practitioners, enforcing standards and correcting when necessary. Review of longitudinal outcome data and communication with all perioperative staff. |
Surgical services staff (surgeons, anesthesiologists/CRNAs, perioperative nurses and technicians) | Ensure execution of prevention measures consistently for all procedures. Escalate questions and concerns to senior surgical leadership. | SSI prevention process measurement, individual reinforcement, support, and correction as indicated. |
Pharmacists | Ensure proper medications for SSI prevention are available when needed. Promote evidence-based, cost-effective choice of antimicrobial prophylaxis. | Track utilization patterns and adverse drug events to ensure proper use of drugs for SSI prevention. Communicate changes and their rationale (eg, drug shortage, new evidence) |
Infection preventionists | Ensure surveillance for SSI is thorough and aligns with national standards. Support prevention efforts as subject-matter experts, coaches, and observers of process and outcome. Educate staff and audit compliance on practical application361 of infection control related policies and processes | Validation of surveillance methodology with transparency to all partners. Assess SSI prevention system as a whole to identify gaps and opportunities. |
Environmental services staff | Ensure correct processes for cleaning perioperative and related areas, and adequate number, training, and support of staff. | Track benchmarks and conduct process and performance reviews regularly. |
Information services | Support SSI prevention efforts through data collection automation and analysis, leverage different platforms (electronic health record, billing databases) to ensure standard and consistent data streams. | Validate systems regularly and whenever updated, maintain flexibility for changes as needs evolve. Engage with other partners if changes are anticipated. Communicate changes to all partners. |
Acknowledgments.
The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).
Footnotes
Conflicts of interest. The following disclosures reflect what has been reported to SHEA. To provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of relevancy to the topic. Such relationships as potential conflicts of interest are evaluated in a review process that includes assessment by the SHEA Conflict of Interest Committee and may include the Board of Trustees and Editor of Infection Control and Hospital Epidemiology. The assessment of disclosed relationships for possible conflicts of interest has been based on the relative weight of the financial relationship (i.e., monetary amount) and the relevance of the relationship (i.e., the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). D.J.A. is the owner of Infection Control Education for Major Sports, LLC, has grants from CDC and AHRQ and has received royalties for authorship on UpToDate. A.C.N. is the Chair DSMB, CAV-AVI Neonatal PK Study with Pfizer. All other authors report no conflicts of interest related to this article.
References
- 1.Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:605–627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.The SHEA Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents, 2021. Society for Healthcare Epidemiology of America; website. https://shea-online.org/wp-content/uploads/2022/02/2022-Handbook-Update-Approved-Posted.pdf. Published August 2021. Accessed March 28, 2023. [Google Scholar]
- 3.National Health Safety Network. Current HAI Progress Report, 2021 Centers for Disease Control and Prevention; website. https://www.cdc.gov/hai/data/portal/progress-report.html. Updated November 4, 2022. Accessed 2022. [Google Scholar]
- 4.Berrios-Torres SI, Umscheid CA, Bratzler D, et al. Centers for Disease Control and Prevention Guideline for prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–791. [DOI] [PubMed] [Google Scholar]
- 5.Baker AW, Dicks KV, Durkin MJ, et al. Epidemiology of surgical site infection in a community hospital network. Infect Control Hosp Epidemiol 2016;37:519–526. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Dencker EE, Bonde A, Troelsen A, Varadarajan KM, Sillesen M. Postoperative complications: an observational study of trends in the United States from 2012 to 2018. BMC Surg 2021;21:393. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Anderson DJ, Pyatt DG, Weber DJ, Rutala WA, North Carolina Department of Public Health HAIAG. Statewide costs of healthcare-associated infections: estimates for acute-care hospitals in North Carolina. Am J Infect Control 2013;41:764–768. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gantz O, Zagadailov P, Merchant AM. The cost of surgical site infections after colorectal surgery in the United States from 2001 to 2012: a longitudinal analysis. Am Surg 2019;85:142–149. [PubMed] [Google Scholar]
- 9.Lewis SS, Moehring RW, Chen LF, Sexton DJ, Anderson DJ. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol 2013;34:1229–1230. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of healthcare-associated infections. N Engl J Med 2014;370:1198–1208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Zimlichman E, Henderson D, Tamir O, et al. Healthcare-associated infections: a meta-analysis of costs and financial impact on the US healthcare system. JAMA Intern Med 2013;173:2039–2046. [DOI] [PubMed] [Google Scholar]
- 12.Meeks DW, Lally KP, Carrick MM, et al. Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? Am J Surg 2011;201:76–83. [DOI] [PubMed] [Google Scholar]
- 13.Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101–114. [DOI] [PubMed] [Google Scholar]
- 14.Cruse P. Wound infection surveillance. Rev Infect Dis 1981;3:734–737. [DOI] [PubMed] [Google Scholar]
- 15.Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin N Am 1980;60:27–40. [DOI] [PubMed] [Google Scholar]
- 16.Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multicenter matched-outcomes study. PLoS One 2009;4:e8305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003;36:592–598. [DOI] [PubMed] [Google Scholar]
- 18.Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725–730. [DOI] [PubMed] [Google Scholar]
- 19.Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999, Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–278. [DOI] [PubMed] [Google Scholar]
- 20.Apisarnthanarak A, Jones M, Waterman BM, Carroll CM, Bernardi R, Fraser VJ. Risk factors for spinal surgical site infections in a community hospital: a case-control study. Infect Control Hosp Epidemiol 2003;24:31–36. [DOI] [PubMed] [Google Scholar]
- 21.Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open-heart surgery. Infect Control Hosp Epidemiol 1990;11:89–93. [DOI] [PubMed] [Google Scholar]
- 22.Bozic KJ, Katz P, Cisternas M, Ono L, Ries MD, Showstack J. Hospital resource utilization for primary and revision total hip arthroplasty. J Bone Joint Surg Am 2005;87:570–576. [DOI] [PubMed] [Google Scholar]
- 23.Coello R, Glenister H, Fereres J, et al. The cost of infection in surgical patients: a case–control study. J Hosp Infect 1993;25:239–250. [DOI] [PubMed] [Google Scholar]
- 24.Hollenbeak CS, Murphy DM, Koenig S, Woodward RS, Dunagan WC, Fraser VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000;118:397–402. [DOI] [PubMed] [Google Scholar]
- 25.VandenBergh MF, Kluytmans JA, van Hout BA, et al. Cost-effectiveness of perioperative mupirocin nasal ointment in cardiothoracic surgery. Infect Control Hosp Epidemiol 1996;17:786–792. [DOI] [PubMed] [Google Scholar]
- 26.Vegas AA, Jodra VM, Garcia ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol 1993;9:504–510. [PubMed] [Google Scholar]
- 27.Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002;23:183–189. [DOI] [PubMed] [Google Scholar]
- 28.Moolla MS, Reddy K, Fwemba I, et al. Bacterial infection, antibiotic use and COVID-19: lessons from the intensive care unit. South African Med J Suid-Afrikaanse tydskrif vir geneeskunde 2021;111:575–581. [PubMed] [Google Scholar]
- 29.Shaaban RH, Yassine OG, Bedwani RN, Abu-Sheasha GA. Evaluation of the costing methodology of published studies estimating costs of surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2022;43:898–914. [DOI] [PubMed] [Google Scholar]
- 30.Hasegawa T, Tashiro S, Mihara T, et al. Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis. BJS Open 2022;6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.O’Hara LM, Thom KA, Preas MA. Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): a summary, review, and strategies for implementation. Am J Infect Control 2018;46:602–609. [DOI] [PubMed] [Google Scholar]
- 32.Scott RD. The direct medical costs of healthcare-associated Infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention; website. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Published 2009. Accessed December 14, 2013. [Google Scholar]
- 33.Weiner-Lastinger LM, Abner S, Edwards JR, et al. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: summary of data reported to the National Healthcare Safety Network, 2015–2017. Infect Control Hosp Epidemiol 2020;41:1–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.The NHSN standardized infection ratio (SIR): a guide to the SIR. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf. Published February 2021. Accessed March 30, 2023. [Google Scholar]
- 35.National Health Safety Network. Surgical site infection (SSI) event, 2013. Centers for Disease Control and Prevention; website. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. Published 2013. Accessed March 30, 2023. [Google Scholar]
- 36.State HAI plans. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/cms/index.html. Accessed March 30, 2023. [Google Scholar]
- 37.National Healthcare Safety Network. CMS Reporting Requirements. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/cms/index.html. Accessed March 30, 2023. [Google Scholar]
- 38.State HAI plans, June 2020. Centers for Disease Control and Prevention; website. https://www.cdc.gov/hai/state-based/state-hai-plans.html. Published 2020. Accessed March 30, 2023. [Google Scholar]
- 39.Campwala I, Unsell K, Gupta S. A comparative analysis of surgical wound infection methods: predictive values of the CDC, ASEPSIS, and Southampton scoring systems in evaluating breast reconstruction surgical site infections. Plast Surg (Oakv) 2019;27:93–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Ju MH, Ko CY, Hall BL, Bosk CL, Bilimoria KY, Wick EC. A comparison of 2 surgical site infection monitoring systems. JAMA Surg 2015;150:51–57. [DOI] [PubMed] [Google Scholar]
- 41.National Healthcare Safety Network. Toolkit for data quality checks for reporting facilities, 2021. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/pdfs/validation/2021/2021-nhsn-iv-for-facilities-508.pdf. Published 2021. Accessed March 30, 2023. [Google Scholar]
- 42.National Healthcare Safety Network. NHSN data validation, June 2021. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/validation/index.html. Published 2021. Accessed March 30, 2023. [Google Scholar]
- 43.National Healthcare Safety Network. Surgical site infection event (SSI), 2022. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Published 2022. Accessed March 30, 2023. [Google Scholar]
- 44.Condon RE, Schulte WJ, Malangoni MA, Anderson-Teschendorf MJ. Effectiveness of a surgical wound surveillance program. Arch Surg 1983;118:303–307. [DOI] [PubMed] [Google Scholar]
- 45.Kerstein M, Flower M, Harkavy LM, Gross PA. Surveillance for postoperative wound infections: practical aspects. Am Surg 1978;44:210–214. [PubMed] [Google Scholar]
- 46.Mead PB, Pories SE, Hall P, Vacek PM, Davis JH Jr, Gamelli RL. Decreasing the incidence of surgical wound infections: validation of a surveillance-notification program. Arch Surg 1986;121:458–461. [DOI] [PubMed] [Google Scholar]
- 47.Lober WB, Evans HL. Patient-generated health data in surgical site infection: changing clinical workflow and care delivery. Surg Infect (Larchmt) 2019;20:571–576. [DOI] [PubMed] [Google Scholar]
- 48.Baker C, Luce J, Chenoweth C, Friedman C. Comparison of case-finding methodologies for endometritis after cesarean section. Am J Infect Control 1995;23:27–33. [DOI] [PubMed] [Google Scholar]
- 49.Cardo DM, Falk PS, Mayhall CG. Validation of surgical wound surveillance. Infect Control Hosp Epidemiol 1993;14:211–215. [DOI] [PubMed] [Google Scholar]
- 50.Cho SY, Chung DR, Choi JR, et al. Validation of semiautomated surgical site infection surveillance using electronic screening algorithms in 38 surgery categories. Infect Control Hosp Epidemiol 2018;39:931–935. [DOI] [PubMed] [Google Scholar]
- 51.Ming DY, Chen LF, Miller BA, Anderson DJ. The impact of depth of infection and postdischarge surveillance on rate of surgical site infections in a network of community hospitals. Infect Control Hosp Epidemiol 2012;33:276–282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Chalfine A, Cauet D, Lin WC, et al. Highly sensitive and efficient computer-assisted system for routine surveillance for surgical site infection. Infect Control Hosp Epidemiol 2006;27:794–801. [DOI] [PubMed] [Google Scholar]
- 53.Miner AL, Sands KE, Yokoe DS, et al. Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis 2004;10:1931–1937. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Yokoe DS, Noskin GA, Cunnigham SM, et al. Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2004;10:1924–1930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Calderwood MS, Kleinman K, Bratzler DW, et al. Use of Medicare claims to identify US hospitals with a high rate of surgical site infection after hip arthroplasty. Infect Control Hosp Epidemiol 2013;34:31–39. [DOI] [PubMed] [Google Scholar]
- 56.Huang SS, Placzek H, Livingston J, et al. Use of Medicare claims to rank hospitals by surgical site infection risk following coronary artery bypass graft surgery. Infect Control Hosp Epidemiol 2011;32:775–783. [DOI] [PubMed] [Google Scholar]
- 57.Haley VB, Van Antwerpen C, Tserenpuntsag B, et al. Use of administrative data in efficient auditing of hospital-acquired surgical site infections, New York State 2009–2010. Infect Control Hosp Epidemiol 2012;33:565–571. [DOI] [PubMed] [Google Scholar]
- 58.van Rooden SM, Tacconelli E, Pujol M, et al. A framework to develop semiautomated surveillance of surgical site infections: an international multicenter study. Infect Control Hosp Epidemiol 2020;41:194–201. [DOI] [PubMed] [Google Scholar]
- 59.Noorit P, Siribumrungwong B, Thakkinstian A. Clinical prediction score for superficial surgical site infection after appendectomy in adults with complicated appendicitis. World J Emerg Surg 2018;13:23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Zhu Y, Simon GJ, Wick EC, et al. Applying machine learning across sites: external validation of a surgical site infection detection algorithm. J Am Coll Surg 2021;232:963–971. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Grundmeier RW, Xiao R, Ross RK, et al. Identifying surgical site infections in electronic health data using predictive models. J Am Med Inform Assoc 2018;25:1160–1166. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Yokoe DS, Avery TR, Platt R, Huang SS. Reporting surgical site infections following total hip and knee arthroplasty: impact of limiting surveillance to the operative hospital. Clin Infect Dis 2013;57:1282–1288. [DOI] [PubMed] [Google Scholar]
- 63.National action plan to prevent health care-associated infections: Roadmap to elimination: ambulatory surgical centers. US Health and Human services; website. http://www.hhs.gov/ash/initiatives/hai/ambulatory_surgical_centers.html. Published January 4, 2013. Accessed March 30, 2023. [Google Scholar]
- 64.Pop-Vicas A, Stern R, Osman F, Safdar N. Variability in infection surveillance methods and impact on surgical site infection rates. Am J Infect Control 2021;49:188–193. [DOI] [PubMed] [Google Scholar]
- 65.Kent P, McDonald M, Harris O, Mason T, Spelman D. Postdischarge surgical wound infection surveillance in a provincial hospital: follow-up rates, validity of data and review of the literature. ANZ J Surg 2001;71:583–589. [DOI] [PubMed] [Google Scholar]
- 66.Mannien J, Wille JC, Snoeren RL, van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands. Infect Control Hosp Epidemiol 2006;27:809–816. [DOI] [PubMed] [Google Scholar]
- 67.Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996;173:963–970. [DOI] [PubMed] [Google Scholar]
- 68.Fields AC, Pradarelli JC, Itani KMF. Preventing surgical site infections: looking beyond the current guidelines. JAMA 2020;323:1087–1088. [DOI] [PubMed] [Google Scholar]
- 69.Segreti J, Parvizi J, Berbari E, Ricks P, Berrios-Torres SI. Introduction to the Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee guideline for prevention of surgical site infection: prosthetic joint arthroplasty section. Surg Infect (Larchmt) 2017;18:394–400. [DOI] [PubMed] [Google Scholar]
- 70.Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg 2017;224:59–74. [DOI] [PubMed] [Google Scholar]
- 71.World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection. Geneva: WHO Guidelines Review Committee; 2018. [Google Scholar]
- 72.Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol 2019;40:1–17. [DOI] [PubMed] [Google Scholar]
- 73.Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195–283. [DOI] [PubMed] [Google Scholar]
- 74.Calderwood MS, Yokoe DS, Murphy MV, et al. Effectiveness of a multistate quality improvement campaign in reducing risk of surgical site infections following hip and knee arthroplasty. BMJ Qual Saf 2019;28:374–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75.Griffin FA. Reducing surgical complications. Jt Comm J Qual Pat Saf 2007;33:660–665. [DOI] [PubMed] [Google Scholar]
- 76.A resource from the Institute of Healthcare Improvement, Institute for Health Care Improvement. Institute of Healthcare Improvement; website. www.ihi.org. Published January 31, 2007. Accessed March 30, 2023. [Google Scholar]
- 77.Centers for Medicare & Medicaid Services. Hospital Care Compare. Website: https://www.medicare.gov/care-compare/?providerType=Hospital
- 78.Hospital quality initiative public reporting: Hospital Care Compare and Provider Data Catalog. Centers for Medicare & Medicaid Services; website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalCompare. Updated October 2022. Accessed March 30, 2023. [Google Scholar]
- 79.Hospital-acquired condition reduction program. Centers for Medicare & Medicaid Services; website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program. Updated August 2022. Accessed March 30, 2023. [Google Scholar]
- 80.The Hospital Value-Based Purchasing (VBP) Program. Centers for Medicare & Medicaid Services; website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing. Accessed March 30, 2023. [Google Scholar]
- 81.NHSN Educational Roadmaps: CDC, NCEZID, DHQP. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/training/roadmap/index.html. Updated February 23, 2022. Accessed March 30, 2023. [Google Scholar]
- 82.Clifford RJ, Newhart D, Laguio-Vila MR, Gutowski JL, Bronstein MZ, Lesho EP. Infection preventionist staffing levels and rates of 10 types of healthcare-associated infections: a 9-year ambidirectional observation. Infect Control Hosp Epidemiol 2022;43:1641–1646. [DOI] [PubMed] [Google Scholar]
- 83.van Kasteren ME, Mannien J, Kullberg BJ, et al. Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multisite intervention by time-series analysis. J Antimicrob Chemother 2005;56:1094–1102. [DOI] [PubMed] [Google Scholar]
- 84.Ahuja S, Peiffer-Smadja N, Peven K, et al. Use of feedback data to reduce surgical site infections and optimize antibiotic use in surgery: a systematic scoping review. Ann Surg 2022;275:e345–e352. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 85.Johnson KM, Newman KL, Green PK, et al. Incidence and risk factors of postoperative mortality and morbidity after elective versus emergent abdominal surgery in a national sample of 8,193 patients with cirrhosis. Ann Surg 2021;274:e345–e354. [DOI] [PubMed] [Google Scholar]
- 86.Schweon S. Stamping out surgical site infections. RN 2006;69:36–40. [PubMed] [Google Scholar]
- 87.Torpy JM, Burke A, Glass RM. JAMA patient page. Wound infections. JAMA 2005;294:2122. [DOI] [PubMed] [Google Scholar]
- 88.Kanter G, Connelly NR, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg 2006;103:1517–1521. [DOI] [PubMed] [Google Scholar]
- 89.Nair BG, Newman SF, Peterson GN, Wu WY, Schwid HA. Feedback mechanisms including real-time electronic alerts to achieve near 100% timely prophylactic antibiotic administration in surgical cases. Anesth Analg 2010;111:1293–1300. [DOI] [PubMed] [Google Scholar]
- 90.Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996;124:884–890. [DOI] [PubMed] [Google Scholar]
- 91.Webb AL, Flagg RL, Fink AS. Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration. Am J Surg 2006;192:663–668. [DOI] [PubMed] [Google Scholar]
- 92.Cato KD, Liu J, Cohen B, Larson E. Electronic surveillance of surgical site infections. Surg Infect (Larchmt) 2017;18:498–502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 93.Bratzler DW, Houck PM, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706–1715. [DOI] [PubMed] [Google Scholar]
- 94.Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006;43:322–330. [DOI] [PubMed] [Google Scholar]
- 95.Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009;250:10–16. [DOI] [PubMed] [Google Scholar]
- 96.van Kasteren ME, Mannien J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 2007;44:921–927. [DOI] [PubMed] [Google Scholar]
- 97.Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK. Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database Syst Rev 2014:CD009516. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 98.Soriano A, Bori G, Garcia-Ramiro S, et al. Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia. Clin Infect Dis 2008;46:1009–1014. [DOI] [PubMed] [Google Scholar]
- 99.Beltran RJ, Kako H, Chovanec T, Ramesh A, Bissonnette B, Tobias JD. Penicillin allergy and surgical prophylaxis: cephalosporin cross-reactivity risk in a pediatric tertiary care center. J Pediatr Surg 2015;50:856–859. [DOI] [PubMed] [Google Scholar]
- 100.Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis 2018;66:329–336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 101.Lam PW, Tarighi P, Elligsen M, et al. Self-reported beta-lactam allergy and the risk of surgical site infection: a retrospective cohort study. Infect Control Hosp Epidemiol 2020;41:438–443. [DOI] [PubMed] [Google Scholar]
- 102.de Jonge SW, Boldingh QJJ, Koch AH, et al. Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, an observational cohort study. Ann Surg 2021;274:e308–e314. [DOI] [PubMed] [Google Scholar]
- 103.Takemoto RC, Lonner B, Andres T, et al. Appropriateness of twenty-four–hour antibiotic prophylaxis after spinal surgery in which a drain is utilized: a prospective randomized study. J Bone Joint Surg Am 2015;97:979–986. [DOI] [PubMed] [Google Scholar]
- 104.Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation 2000;101:2916–2921. [DOI] [PubMed] [Google Scholar]
- 105.McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg 1998;68:388–396. [DOI] [PubMed] [Google Scholar]
- 106.Miranda D, Mermel LA, Dellinger EP. Perioperative antibiotic prophylaxis: surgeons as antimicrobial stewards. J Am Coll Surg 2020;231:766–768. [DOI] [PubMed] [Google Scholar]
- 107.Branch-Elliman W, O’Brien W, Strymish J, Itani K, Wyatt C, Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg 2019;154:590–598. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 108.Li T, Zhang H, Chan PK, Fung WC, Fu H, Chiu KY. Risk factors associated with surgical site infections following joint replacement surgery: a narrative review. Arthroplasty 2022;4:11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 109.Ahmadzia HK, Patel EM, Joshi D, et al. Obstetric surgical site infections: 2 grams compared with 3 grams of cefazolin in morbidly obese women. Obstet Gynecol 2015;126:708–715. [DOI] [PubMed] [Google Scholar]
- 110.Swank ML, Wing DA, Nicolau DP, McNulty JA. Increased 3-gram cefazolin dosing for cesarean delivery prophylaxis in obese women. Am J Obstet Gynecol 2015;213:415 e1–e8. [DOI] [PubMed] [Google Scholar]
- 111.Morris AJ, Roberts SA, Grae N, Frampton CM. Surgical site infection rate is higher following hip and knee arthroplasty when cefazolin is under-dosed. Am J Health Syst Pharm 2020;77:434–440. [DOI] [PubMed] [Google Scholar]
- 112.Salm L, Marti WR, Stekhoven DJ, et al. Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical site infection rates. BJS Open 2021;5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 113.Benefield EC, Hagemann TM, Allen HC, et al. Vancomycin dosing and pharmacokinetics in postoperative pediatric cardiothoracic surgery patients. J Pediatr Pharmacol Ther 2016;21:66–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 114.Bauer LA, Edwards WA, Dellinger EP, Simonowitz DA. Influence of weight on aminoglycoside pharmacokinetics in normal weight and morbidly obese patients. Eur J Clin Pharmacol 1983;24:643–647. [DOI] [PubMed] [Google Scholar]
- 115.Rollins KE, Javanmard-Emamghissi H, Lobo DN. Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis. World J Gastroenterol 2018;24:519–536. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 116.Toh JWT, Phan K, Hitos K, et al. Association of mechanical bowel preparation and oral antibiotics before elective colorectal surgery with surgical site infection: a network meta-analysis. JAMA Netw Open 2018;1:e183226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 117.Rollins KE, Javanmard-Emamghissi H, Acheson AG, Lobo DN. The role of oral antibiotic preparation in elective colorectal surgery: a meta-analysis. Ann Surg 2019;270:43–58. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 118.Woodfield JC, Clifford K, Schmidt B, Turner GA, Amer MA, McCall JL. Strategies for antibiotic administration for bowel preparation among patients undergoing elective colorectal surgery: a network meta-analysis. JAMA Surg 2022;157:34–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 119.Espin Basany E, Solís-Peña A, Pellino G, et al. Preoperative oral antibiotics and surgical site infections in colon surgery (ORALEV): a multicentre, single-blind, pragmatic, randomised controlled trial. Lancet Gastroenterol Hepatol 2020;5:729–738. [DOI] [PubMed] [Google Scholar]
- 120.Koskenvuo L, Lehtonen T, Koskensalo S, et al. Mechanical and oral antibiotic bowel preparation versus no bowel preparation for elective colectomy (MOBILE): a multicentre, randomised, parallel, single-blinded trial. Lancet 2019;394:840–848. [DOI] [PubMed] [Google Scholar]
- 121.Rybakov E, Nagudov M, Sukhina M, Shelygin Y. Impact of oral antibiotic prophylaxis on surgical site infection after rectal surgery: results of randomized trial. Int J Colorectal Dis 2021;36:323–330. [DOI] [PubMed] [Google Scholar]
- 122.Lee JH, Ahn BK, Ryu J, Lee KH. Mechanical bowel preparation combined with oral antibiotics in colorectal cancer surgery: a nationwide population-based study. Int J Colorectal Dis 2021;36:1929–1935. [DOI] [PubMed] [Google Scholar]
- 123.Papp G, Saftics G, Szabó BE, et al. Systemic versus Oral and Systemic Antibiotic Prophylaxis (SOAP) study in colorectal surgery: prospective randomized multicentre trial. Br J Surg 2021;108:271–276. [DOI] [PubMed] [Google Scholar]
- 124.Pop-Vicas A, Safdar N. Preoperative decolonization as a strategy to reduce surgical site infection. Curr Infect Dis Rep 2019;21:35. [DOI] [PubMed] [Google Scholar]
- 125.Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease gram-positive surgical site infections after cardiac or orthopedic surgery: systematic review and meta-analysis. BMJ 2013;346:f2743. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 126.Bode LG, Kluytmans JA, Wertheim HF, et al. Preventing surgical site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010;362:9–17. [DOI] [PubMed] [Google Scholar]
- 127.Bode LG, van Rijen MM, Wertheim HF, et al. Long-term mortality after rapid screening and decolonization of Staphylococcus aureus carriers: observational follow-up study of a randomized, placebo-controlled trial. Ann Surg 2016;263:511–515. [DOI] [PubMed] [Google Scholar]
- 128.Schweizer ML, Chiang HY, Septimus E, et al. Association of a bundled intervention with surgical site infections among patients undergoing cardiac, hip, or knee surgery. JAMA 2015;313:2162–2171. [DOI] [PubMed] [Google Scholar]
- 129.Kline SE, Sanstead EC, Johnson JR, Kulasingam SL. Cost-effectiveness of preoperative Staphylococcus aureus screening and decolonization. Infect Control Hosp Epidemiol 2018;39:1340–1346. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 130.Stambough JB, Nam D, Warren DK, et al. Decreased hospital costs and surgical site infection incidence with a universal decolonization protocol in primary total joint arthroplasty. J Arthroplasty 2017;32:728–734. [DOI] [PubMed] [Google Scholar]
- 131.Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA 2008;299:1149–1157. [DOI] [PubMed] [Google Scholar]
- 132.Lee AS, Cooper BS, Malhotra-Kumar S, et al. Comparison of strategies to reduce meticillin-resistant Staphylococcus aureus rates in surgical patients: a controlled multicentre intervention trial. BMJ Open 2013;3:e003126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 133.Lee AS, Cooper BS, Malhotra-Kumar S, et al. Comparison of strategies to reduce meticillin-resistant Staphylococcus aureus rates in surgical patients: a controlled multicentre intervention trial. BMJ Open 2013;3:e003126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 134.Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002;346:1871–1877. [DOI] [PubMed] [Google Scholar]
- 135.van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev 2008:CD006216. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 136.Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996;17:811–813. [DOI] [PubMed] [Google Scholar]
- 137.Phillips M, Rosenberg A, Shopsin B, et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidemiol 2014;35:826–832. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 138.Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg 2015;150:390–395. [DOI] [PubMed] [Google Scholar]
- 139.Urias DS, Varghese M, Simunich T, Morrissey S, Dumire R. Preoperative decolonization to reduce infections in urgent lower extremity repairs. Eur J Trauma Emerg Surg 2018;44:787–793. [DOI] [PubMed] [Google Scholar]
- 140.Kaul AF, Jewett JF. Agents and techniques for disinfection of the skin. Surg Gynecol Obstet 1981;152:677–685. [PubMed] [Google Scholar]
- 141.Moores N, Rosenblatt S, Prabhu A, Rosen M. Do iodine-impregnated adhesive surgical drapes reduce surgical site infections during open ventral hernia repair? A comparative analysis. Am Surg 2017;83:617–622. [PubMed] [Google Scholar]
- 142.Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2007:CD004985. [DOI] [PubMed] [Google Scholar]
- 143.Edmiston CE Jr., Krepel CJ, Seabrook GR, Lewis BD, Brown KR, Towne JB. Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission? J Am Coll Surg 2008;207:233–239. [DOI] [PubMed] [Google Scholar]
- 144.Eiselt D. Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthoped Nurs 2009;28:141–145. [DOI] [PubMed] [Google Scholar]
- 145.Rhee Y, Palmer LJ, Okamoto K, et al. Differential effects of chlorhexidine skin cleansing methods on residual chlorhexidine skin concentrations and bacterial recovery. Infect Control Hosp Epidemiol 2018;39:405–411. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 146.Haas DM, Morgan S, Contreras K, Kimball S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev 2020;4:CD007892. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 147.Hill AM, Pauls RN, Basil J, et al. Chlorhexidine versus iodine for vaginal preparation before hysterectomy: a randomized clinical trial. Female Pelvic Med Reconstr Surg 2022;28:77–84. [DOI] [PubMed] [Google Scholar]
- 148.Grober ED, Domes T, Fanipour M, Copp JE. Preoperative hair removal on the male genitalia: clippers vs. razors. J Sex Med 2013;10:589–594. [DOI] [PubMed] [Google Scholar]
- 149.Maiwald M, Chan ES. The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis. PLoS One 2012;7:e44277. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 150.Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Liu Z. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2015;4:CD003949. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 151.Tuuli MG, Liu J, Stout MJ, et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016;374:647–655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 152.Ritter B, Herlyn PKE, Mittlmeier T, Herlyn A. Preoperative skin antisepsis using chlorhexidine may reduce surgical wound infections in lower limb trauma surgery when compared to povidone-iodine—a prospective randomized trial. Am J Infect Control 2020;48:167–172. [DOI] [PubMed] [Google Scholar]
- 153.Broach RB, Paulson EC, Scott C, Mahmoud NN. Randomized controlled trial of two alcohol-based preparations for surgical site antisepsis in colorectal surgery. Ann Surg 2017;266:946–951. [DOI] [PubMed] [Google Scholar]
- 154.Charehbili A, Koek MBG, de Mol van Otterloo JCA, et al. Cluster-randomized crossover trial of chlorhexidine-alcohol versus iodine-alcohol for prevention of surgical site infection (SKINFECT trial). BJS Open 2019;3:617–622. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 155.Aho Glele LS, Ortega-Deballon P, Guilloteau A, Keita-Perse O, Astruc K, Lepelletier D. Cluster-randomized crossover trial of chlorhexidine-alcohol versus iodine-alcohol for prevention of surgical site infection (SKINFECT trial). BJS Open 2020;4:731–733. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 156.Aly R, Maibach HI. Comparative antibacterial efficacy of a 2-minute surgical scrub with chlorhexidine gluconate, povidone-iodine, and chloroxylenol sponge brushes. Am J Infect Control 1988;16:173–177. [DOI] [PubMed] [Google Scholar]
- 157.Larson E. Guideline for use of topical antimicrobial agents. Am J Infect Control 1988;16:253–266. [DOI] [PubMed] [Google Scholar]
- 158.Chapman AK, Aucott SW, Milstone AM. Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. J Perinatol 2012;32:4–9. [DOI] [PubMed] [Google Scholar]
- 159.Carr S, Gogal C, Afshar K, Ting J, Skarsgard E. Optimizing skin antisepsis for neonatal surgery: a quality improvement initiative. J Pediatr Surg 2022;57:1235–1241. [DOI] [PubMed] [Google Scholar]
- 160.Dramowski A, Pillay S, Bekker A, et al. Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates—a pilot clinical trial. EClinicalMedicine 2021;37:100946. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 161.Jain A, Deshpande P, Yoon EW, Lee KS, McGeer A, Shah V. 2% aqueous vs alcohol-based chlorhexidine for skin antisepsis in VLBW neonates undergoing peripheral venipuncture: a noninferiority trial. J Perinatol 2022;42:636–641. [DOI] [PubMed] [Google Scholar]
- 162.Sharma A, Kulkarni S, Thukral A, et al. Aqueous chlorhexidine 1% versus 2% for neonatal skin antisepsis: a randomised noninferiority trial. Arch Dis Child Fetal Neonatal Ed 2021;106:643–648. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 163.Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology 2001;95:531–543. [DOI] [PubMed] [Google Scholar]
- 164.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 1996;334:1209–1215. [DOI] [PubMed] [Google Scholar]
- 165.Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001;358:876–880. [DOI] [PubMed] [Google Scholar]
- 166.Wong PF, Kumar S, Bohra A, Whetter D, Leaper DJ. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007;94:421–426. [DOI] [PubMed] [Google Scholar]
- 167.Zheng XQ, Huang JF, Lin JL, Chen D, Wu AM. Effects of preoperative warming on the occurrence of surgical site infection: a systematic review and meta-analysis. Int J Surg 2020;77:40–47. [DOI] [PubMed] [Google Scholar]
- 168.Lau A, Lowlaavar N, Cooke EM, et al. Effect of preoperative warming on intraoperative hypothermia: a randomized-controlled trial. Can J Anaesth 2018;65:1029–1040. [DOI] [PubMed] [Google Scholar]
- 169.Kang SI, Oh HK, Kim MH, et al. Systematic review and meta-analysis of randomized controlled trials of the clinical effectiveness of impervious plastic wound protectors in reducing surgical site infections in patients undergoing abdominal surgery. Surgery 2018;164:939–945. [DOI] [PubMed] [Google Scholar]
- 170.Bressan AK, Aubin JM, Martel G, et al. Efficacy of a dual-ring wound protector for prevention of surgical site infections after pancreaticoduodenectomy in patients with intrabiliary stents: a randomized clinical trial. Ann Surg 2018;268:35–40. [DOI] [PubMed] [Google Scholar]
- 171.Whiteside OJ, Tytherleigh MG, Thrush S, Farouk R, Galland RB. Intraoperative peritoneal lavage—who does it and why? Ann R Coll Surg Engl 2005;87:255–258. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 172.Ambe PC, Rombey T, Rembe JD, Dorner J, Zirngibl H, Pieper D. The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis. Patient Saf Surg 2020;14:47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 173.Norman G, Atkinson RA, Smith TA, et al. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev 2017;10:CD012234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 174.Mueller TC, Loos M, Haller B, et al. Intraoperative wound irrigation to reduce surgical site infections after abdominal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2015;400:167–181. [DOI] [PubMed] [Google Scholar]
- 175.Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intracavity lavage and wound irrigation for prevention of surgical site infection: systematic review and network meta-analysis. Surg Infect (Larchmt) 2021;22:144–167. [DOI] [PubMed] [Google Scholar]
- 176.Lopez-Cano M, Kraft M, Curell A, et al. Use of topical antibiotics before primary incision closure to prevent surgical site infection: a meta-analysis. Surg Infect (Larchmt) 2019;20:261–270. [DOI] [PubMed] [Google Scholar]
- 177.FDA requests withdrawal of bacitracin for injection from market, January 31, 2020. US Food and Drug Administration; website. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requests-withdrawal-bacitracin-injection-market. Published January 31, 2020. Accessed March 30, 2023. [Google Scholar]
- 178.Strobel RM, Leonhardt M, Krochmann A, et al. Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: a randomized controlled trial. Ann Surg 2020;272:55–64. [DOI] [PubMed] [Google Scholar]
- 179.De Santo LS, Rubino AS, Torella M, et al. Topical rifampicin for prevention of deep sternal wound infections in patients undergoing coronary artery bypass grafting. Sci Rep 2020;10:7400. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 180.Kwon S, Thompson R, Dellinger P, Yanez D, Farrohki E, Flum D. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg 2013;257:8–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 181.Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006;141:375–380. [DOI] [PubMed] [Google Scholar]
- 182.Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999;22:1408–1414. [DOI] [PubMed] [Google Scholar]
- 183.Olsen MA, Lefta M, Dietz JR, et al. Risk factors for surgical site infection after major breast operation. J Am Coll Surg 2008;207:326–335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 184.Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011;34:256–261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 185.Wang Y-Y, Hu S-F, Ying H-M, et al. Postoperative tight glycemic control significantly reduces postoperative infection rates in patients undergoing surgery: a meta-analysis. BMC Endocr Disord 2018;18:42. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 186.Ogawa S, Okawa Y, Sawada K, et al. Continuous postoperative insulin infusion reduces deep sternal wound infection in patients with diabetes undergoing coronary artery bypass grafting using bilateral internal mammary artery grafts: a propensity-matched analysis. Eur J Cardiothorac Surg 2016;49:420–426. [DOI] [PubMed] [Google Scholar]
- 187.Okabayashi T, Shima Y, Sumiyoshi T, et al. Intensive versus intermediate glucose control in surgical intensive care unit patients. Diabetes Care 2014;37:1516–1524. [DOI] [PubMed] [Google Scholar]
- 188.Al-Niaimi AN, Ahmed M, Burish N, et al. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol 2015;136:71–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 189.WHO surgical safety checklist. World Health Organization; website. https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources. Accessed March 30, 2023. [Google Scholar]
- 190.Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–499. [DOI] [PubMed] [Google Scholar]
- 191.van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 2012;255:44–49. [DOI] [PubMed] [Google Scholar]
- 192.Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010;251:976–980. [DOI] [PubMed] [Google Scholar]
- 193.Pop-Vicas AE, Abad C, Baubie K, Osman F, Heise C, Safdar N. Colorectal bundles for surgical site infection prevention: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2020;41:805–812. [DOI] [PubMed] [Google Scholar]
- 194.Lee JT. Wound infection surveillance. Infect Dis Clin N Am 1992;6:643–656. [PubMed] [Google Scholar]
- 195.Dellinger EP, Villaflor-Camagong D, Whimbey E. Gradually increasing surgical site infection prevention bundle with monitoring of potentially preventable infections resulting in decreasing overall surgical site infection rate. Surg Infect (Larchmt) 2021;22:1072–1076. [DOI] [PubMed] [Google Scholar]
- 196.Bolon MK, Hooper D, Stevenson KB, et al. Improved surveillance for surgical site infections after orthopedic implantation procedures: extending applications for automated data. Clin Infect Dis 2009;48:1223–1229. [DOI] [PubMed] [Google Scholar]
- 197.Calderwood MS, Ma A, Khan YM, et al. Use of Medicare diagnosis and procedure codes to improve detection of surgical site infections following hip arthroplasty, knee arthroplasty, and vascular surgery. Infect Control Hosp Epidemiol 2012;33:40–49. [DOI] [PubMed] [Google Scholar]
- 198.Gerbier-Colomban S, Bourjault M, Cetre JC, Baulieux J, Metzger MH. Evaluation study of different strategies for detecting surgical site infections using the hospital information system at Lyon University Hospital, France. Ann Surg 2012;255:896–900. [DOI] [PubMed] [Google Scholar]
- 199.Yokoe DS, Khan Y, Olsen MA, et al. Enhanced surgical site infection surveillance following hysterectomy, vascular, and colorectal surgery. Infect Control Hosp Epidemiol 2012;33:768–773. [DOI] [PubMed] [Google Scholar]
- 200.Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006:CD000259. [DOI] [PubMed] [Google Scholar]
- 201.National surgical quality improvement. American College of Surgeons; website. https://www.facs.org/quality-programs/data-and-registries/acs-nsqip. Accessed March 30, 2023. [Google Scholar]
- 202.Skoufalos A, Clarke JL, Napp M, et al. Improving awareness of best practices to reduce surgical site infection: a multistakeholder approach. Am J Med Qual 2012;27:297–304. [DOI] [PubMed] [Google Scholar]
- 203.Tips for safer surgery. Institute for Health Care Improvement; website. https://www.ihi.org/resources/Pages/Tools/TipsforSaferSurgery.aspx. Accessed March 30, 2023. [Google Scholar]
- 204.Frequently asked questions about surgical site infections, May 2019. Centers for Disease Control and Prevention; website. https://www.cdc.gov/hai/ssi/faq_ssi.html. Published 2019. Accessed March 30, 2023. [Google Scholar]
- 205.For our patients and their visitors: help prevent infections. Society for Healthcare Epidemiology of America; website. www.shea-online.org. Accessed March 30, 2023. [Google Scholar]
- 206.Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg 2012;114:1236–1248. [DOI] [PubMed] [Google Scholar]
- 207.Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. Am J Infect Control 2012;40:750–755. [DOI] [PubMed] [Google Scholar]
- 208.Crolla RM, van der Laan L, Veen EJ, Hendriks Y, van Schendel C, Kluytmans J. Reduction of surgical site infections after implementation of a bundle of care. PLoS One 2012;7:e44599. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 209.Marra AR, Diekema DJ, Edmond MB. Successful termination of an outbreak of Mycobacterium chimaera infections associated with contaminated heater-cooler devices. Infect Control Hosp Epidemiol 2021;42:471–473. [DOI] [PubMed] [Google Scholar]
- 210.van Ingen J, Kohl TA, Kranzer K, et al. Global outbreak of severe Mycobacterium chimaera disease after cardiac surgery: a molecular epidemiological study. Lancet Infect Dis 2017;17:1033–41. [DOI] [PubMed] [Google Scholar]
- 211.Haessler S, Connelly NR, Kanter G, et al. A surgical site infection cluster: the process and outcome of an investigation—the impact of an alcohol-based surgical antisepsis product and human behavior. Anesth Analg 2010;110:1044–1048. [DOI] [PubMed] [Google Scholar]
- 212.Panahi P, Stroh M, Casper DS, Parvizi J, Austin MS. Operating room traffic is a major concern during total joint arthroplasty. Clin Orthop Relat Res 2012;470:2690–2694. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 213.Tadros MA, Williams VR, Plourde S, Callery S, Simor AE, Vearncombe M. Risk factors for Staphylococcus aureus surgical site infection during an outbreak in patients undergoing cardiovascular surgery. Am J Infect Control 2013;41:509–512. [DOI] [PubMed] [Google Scholar]
- 214.Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control 2011;39:555–559. [DOI] [PubMed] [Google Scholar]
- 215.Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41:33–38. [DOI] [PubMed] [Google Scholar]
- 216.Thompson KM, Oldenburg WA, Deschamps C, Rupp WC, Smith CD. Chasing zero: the drive to eliminate surgical site infections. Ann Surg 2011;254:430–436. [DOI] [PubMed] [Google Scholar]
- 217.De Vries FEE, Wallert ED, Solomkin JS, et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore) 2016;95:e4673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 218.Norman G, Goh EL, Dumville JC, et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 2020;6:CD009261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 219.Zwanenburg PR, Tol BT, Obdeijn MC, Lapid O, Gans SL, Boermeester MA. Meta-analysis, Meta-regression, and GRADE Assessment of Randomized and Nonrandomized Studies of Incisional Negative Pressure Wound Therapy Versus Control Dressings for the Prevention of Postoperative Wound Complications. Ann Surg 2020;272:81–91. [DOI] [PubMed] [Google Scholar]
- 220.Fowler AL, Barry MK. Closed incision negative pressure therapy: results of recent trials and recommendations for clinical practice. Surgeon. 2020;18:241–250. [DOI] [PubMed] [Google Scholar]
- 221.Meyer J, Roos E, Abbassi Z, Buchs NC, Ris F, Toso C. Prophylactic negative-pressure wound therapy prevents surgical site infection in abdominal surgery: an updated systematic review and meta-analysis of randomized controlled trials and observational studies. Clin Infect Dis 2020. [DOI] [PubMed] [Google Scholar]
- 222.Ailaney N, Johns WL, Golladay GJ, Strong B, Kalore NV. Closed incision negative pressure wound therapy for elective hip and knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplasty 2021;36:2402–2411. [DOI] [PubMed] [Google Scholar]
- 223.Higuera-Rueda CA, Emara AK, Nieves-Malloure Y, et al. The effectiveness of closed-incision negative-pressure therapy versus silver-impregnated dressings in mitigating surgical site complications in high-risk patients after revision knee arthroplasty: the PROMISES randomized controlled trial. J Arthroplasty 2021;36:S295–S302. [DOI] [PubMed] [Google Scholar]
- 224.Almansa-Saura S, Lopez-Lopez V, Eshmuminov D, et al. Prophylactic use of negative pressure therapy in general abdominal surgery: a systematic review and meta-analysis. Surg Infect (Larchmt) 2021;22:854–863. [DOI] [PubMed] [Google Scholar]
- 225.Saunders C, Nherera LM, Horner A, Trueman P. Single-use negative-pressure wound therapy versus conventional dressings for closed surgical incisions: systematic literature review and meta-analysis. BJS Open 2021;5:zraa003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 226.Wells CI, Ratnayake CBB, Perrin J, Pandanaboyana S. Prophylactic negative-pressure wound therapy in closed abdominal incisions: a meta-analysis of randomised controlled trials. World J Surg 2019;43:2779–2788. [DOI] [PubMed] [Google Scholar]
- 227.Kohlenberg A, Weitzel-Kage D, van der Linden P, et al. Outbreak of carbapenem-resistant Pseudomonas aeruginosa infection in a surgical intensive care unit. J Hosp Infect 2010;74:350–357. [DOI] [PubMed] [Google Scholar]
- 228.Elek SD, Conen PE. The virulence of Staphylococcus pyogenes for man; a study of the problems of wound infection. Br J Exp Pathol 1957;38:573–586. [PMC free article] [PubMed] [Google Scholar]
- 229.Olmez T, Berkesoglu M, Turkmenoglu O, Colak T. Effect of triclosan-coated suture on surgical site infection of abdominal fascial closures. Surg Infect (Larchmt) 2019;20:658–664. [DOI] [PubMed] [Google Scholar]
- 230.Ruiz-Tovar J, Llavero C, Jimenez-Fuertes M, Duran M, Perez-Lopez M, Garcia-Marin A. Incisional surgical site infection after abdominal fascial closure with triclosan-coated barbed suture vs triclosan-coated polydioxanone loop suture vs polydioxanone loop suture in emergent abdominal surgery: a randomized clinical trial. J Am Coll Surg 2020;230:766–774. [DOI] [PubMed] [Google Scholar]
- 231.Nakamura T, Kashimura N, Noji T, Suzuki O, Ambo Y, Nakamura F, et al. Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial. Surgery 2013;153:576–583. [DOI] [PubMed] [Google Scholar]
- 232.Chang WK, Srinivasa S, Morton R, Hill AG. Triclosan-impregnated sutures to decrease surgical site infections: systematic review and meta-analysis of randomized trials. Ann Surg 2012;255:854–859. [DOI] [PubMed] [Google Scholar]
- 233.Deliaert AE, Van den Kerckhove E, Tuinder S, et al. The effect of triclosan-coated sutures in wound healing: a double-blind randomised prospective pilot study. J Plast Reconstr Aesthet Surg 2009;62:771–773. [DOI] [PubMed] [Google Scholar]
- 234.Murphy E, Spencer SJ, Young D, Jones B, Blyth MJ. MRSA colonisation and subsequent risk of infection despite effective eradication in orthopaedic elective surgery. J Bone Joint Surg Br 2011;93:548–551. [DOI] [PubMed] [Google Scholar]
- 235.Dodds Ashley ES, Carroll DN, Engemann JJ, et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2004;38:1555–1560. [DOI] [PubMed] [Google Scholar]
- 236.Strymish J, Branch-Elliman W, Itani KM, Williams S, Gupta K. A clinical history of methicillin-resistant Staphylococcus aureus is a poor predictor of preoperative colonization status and postoperative infections. Infect Control Hosp Epidemiol 2012;33:1113–1117. [DOI] [PubMed] [Google Scholar]
- 237.Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than beta-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis 2004;38:1357–1363. [DOI] [PubMed] [Google Scholar]
- 238.Bull AL, Worth LJ, Richards MJ. Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive staphylococcus aureus surgical site infections: report from Australian Surveillance Data (VICNISS). Ann Surg 2012;256:1089–1092. [DOI] [PubMed] [Google Scholar]
- 239.Chambers D, Worthy G, Myers L, et al. Glycopeptide vs nonglycopeptide antibiotics for prophylaxis of surgical site infections: a systematic review. Surg Infect (Larchmt) 2010;11:455–462. [DOI] [PubMed] [Google Scholar]
- 240.Balch A, Wendelboe AM, Vesely SK, Bratzler DW. Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile. PLoS One 2017;12:e0179117. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 241.Branch-Elliman W, Ripollone JE, O’Brien WJ, et al. Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: a national propensity-score-adjusted retrospective cohort study. PLoS Med 2017;14:e1002340. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 242.Brennan MF, Pisters PW, Posner M, Quesada O, Shike M. A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994;220:436–441. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 243.Veterans’ Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. N Engl J Med 1991;325:525–532. [DOI] [PubMed] [Google Scholar]
- 244.Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 2012;255:1060–1068. [DOI] [PubMed] [Google Scholar]
- 245.Zhang Y, Gu Y, Guo T, Li Y, Cai H. Perioperative immunonutrition for gastrointestinal cancer: a systematic review of randomized controlled trials. Surg Oncol 2012;21:e87–e95. [DOI] [PubMed] [Google Scholar]
- 246.Webster J, Alghamdi AA. Use of plastic adhesive drapes during surgery for preventing surgical site infection. Cochrane Database Syst Rev 2007:CD006353. [DOI] [PubMed] [Google Scholar]
- 247.Dewan PA, Van Rij AM, Robinson RG, Skeggs GB, Fergus M. The use of an iodophor-impregnated plastic incise drape in abdominal surgery—a controlled clinical trial. Aust N Z J Surg 1987;57:859–863. [DOI] [PubMed] [Google Scholar]
- 248.Segal CG, Anderson JJ. Preoperative skin preparation of cardiac patients. AORN J 2002;76:821–828. [DOI] [PubMed] [Google Scholar]
- 249.Swenson BR, Camp TR, Mulloy DP, Sawyer RG. Antimicrobial-impregnated surgical incise drapes in the prevention of mesh infection after ventral hernia repair. Surg Infect (Larchmt) 2008;9:23–32. [DOI] [PubMed] [Google Scholar]
- 250.Wetterslev J, Meyhoff CS, Jorgensen LN, Gluud C, Lindschou J, Rasmussen LS. The effects of high perioperative inspiratory oxygen fraction for adult surgical patients. Cochrane Database Syst Rev 2015:CD008884. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 251.Ferrando C, Aldecoa C, Unzueta C, et al. Effects of oxygen on postsurgical infections during an individualised perioperative open-lung ventilatory strategy: a randomised controlled trial. Br J Anaesth 2020;124:110–120. [DOI] [PubMed] [Google Scholar]
- 252.Shaffer SK, Tubog TD, Kane TD, Stortroen NE. Supplemental oxygen and surgical site infection in colorectal surgery: a systematic review and meta-analysis. AANA J 2021;89:245–253. [PubMed] [Google Scholar]
- 253.Smith BK, Roberts RH, Frizelle FA. O(2) no longer the go(2): a systematic review and meta-analysis comparing the effects of giving perioperative oxygen therapy of 30% FiO(2) to 80% FiO(2) on surgical site infection and mortality. World J Surg 2020;44:69–77. [DOI] [PubMed] [Google Scholar]
- 254.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 2005;294:2035–2042. [DOI] [PubMed] [Google Scholar]
- 255.Bickel A, Gurevits M, Vamos R, Ivry S, Eitan A. Perioperative hyperoxygenation and wound site infection following surgery for acute appendicitis: a randomized, prospective, controlled trial. Arch Surg 2011;146:464–470. [DOI] [PubMed] [Google Scholar]
- 256.Greif R, Akca O, Horn EP, Kurz A, Sessler DI, Outcomes Research G. Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. N Engl J Med 2000;342:161–167. [DOI] [PubMed] [Google Scholar]
- 257.Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006;296:2460–2466. [DOI] [PubMed] [Google Scholar]
- 258.de Bruin AF, Gosselink MP, van der Harst E, Rutten HJ. Local application of gentamicin collagen implants in the prophylaxis of surgical site infections following gastrointestinal surgery: a review of clinical experience. Tech Coloproctol 2010;14:301–310. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 259.Guzman Valdivia Gomez G, Guerrero TS, Lluck MC, Delgado FJ. Effectiveness of collagen-gentamicin implant for treatment of “dirty” abdominal wounds. World J Surg 1999;23:123–126. [DOI] [PubMed] [Google Scholar]
- 260.Rutten HJ, Nijhuis PH. Prevention of wound infection in elective colorectal surgery by local application of a gentamicin-containing collagen sponge. Eur J Surg Suppl 1997:31–35. [PubMed] [Google Scholar]
- 261.Bennett-Guerrero E, Berry SM, Bergese SD, et al. A randomized, blinded, multicenter trial of a gentamicin vancomycin gel (DFA-02) in patients undergoing abdominal surgery. Am J Surg 2017;213:1003–1009. [DOI] [PubMed] [Google Scholar]
- 262.Bennett-Guerrero E, Pappas TN, Koltun WA, et al. Gentamicin-collagen sponge for infection prophylaxis in colorectal surgery. N Engl J Med 2010;363:1038–1049. [DOI] [PubMed] [Google Scholar]
- 263.Bennett-Guerrero E, Ferguson TB Jr, Lin M, et al. Effect of an implantable gentamicin-collagen sponge on sternal wound infections following cardiac surgery: a randomized trial. JAMA 2010;304:755–762. [DOI] [PubMed] [Google Scholar]
- 264.Eklund AM, Valtonen M, Werkkala KA. Prophylaxis of sternal wound infections with gentamicin-collagen implant: randomized controlled study in cardiac surgery. J Hosp Infect 2005;59:108–112. [DOI] [PubMed] [Google Scholar]
- 265.Friberg O, Svedjeholm R, Soderquist B, Granfeldt H, Vikerfors T, Kallman J. Local gentamicin reduces sternal wound infections after cardiac surgery: a randomized controlled trial. Ann Thorac Surg 2005;79:153–161. [DOI] [PubMed] [Google Scholar]
- 266.Schimmer C, Ozkur M, Sinha B, et al. Gentamicin-collagen sponge reduces sternal wound complications after heart surgery: a controlled, prospectively randomized, double-blind study. J Thorac Cardiovasc Surg 2012;143:194–200. [DOI] [PubMed] [Google Scholar]
- 267.Kowalewski M, Pawliszak W, Zaborowska K, et al. Gentamicin-collagen sponge reduces the risk of sternal wound infections after heart surgery: meta-analysis. J Thorac Cardiovasc Surg 2015;149:1631–1640. [DOI] [PubMed] [Google Scholar]
- 268.Ravikumar V, Ho AL, Pendhakar AV, Sussman ES, Kwong-Hon Chow K, Li G. The use of vancomycin powder for surgical prophylaxis following craniotomy. Neurosurgery 2017;80:754–758. [DOI] [PubMed] [Google Scholar]
- 269.Haimoto S, Schar RT, Nishimura Y, Hara M, Wakabayashi T, Ginsberg HJ. Reduction in surgical site infection with suprafascial intrawound application of vancomycin powder in instrumented posterior spinal fusion: a retrospective case–control study. J Neurosurg Spine 2018;29:193–198. [DOI] [PubMed] [Google Scholar]
- 270.McCutcheon BA, Ubl DS, Babu M, et al. Predictors of surgical site infection following craniotomy for intracranial neoplasms: an analysis of prospectively collected data in the American College of Surgeons National Surgical Quality Improvement Program Database. World Neurosurg 2016;88:350–358. [DOI] [PubMed] [Google Scholar]
- 271.Adogwa O, Elsamadicy AA, Sergesketter A, et al. Prophylactic use of intraoperative vancomycin powder and postoperative infection: an analysis of microbiological patterns in 1,200 consecutive surgical cases. J Neurosurg Spine 2017;27:328–334. [DOI] [PubMed] [Google Scholar]
- 272.Grabel ZJ, Boden A, Segal DN, Boden S, Milby AH, Heller JG. The impact of prophylactic intraoperative vancomycin powder on microbial profile, antibiotic regimen, length of stay, and reoperation rate in elective spine surgery. Spine J 2019;19:261–266. [DOI] [PubMed] [Google Scholar]
- 273.Gande A, Rosinski A, Cunningham T, Bhatia N, Lee YP. Selection pressures of vancomycin powder use in spine surgery: a meta-analysis. Spine J 2019;19:1076–1084. [DOI] [PubMed] [Google Scholar]
- 274.Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976) 2013;38:2149–2155. [DOI] [PubMed] [Google Scholar]
- 275.A statement from the meeting of ACS, AORN, ASA, APIC, AST, and TJC concerning recommendations for operating room attire. American College of Surgeons; website. https://www.facs.org/about-acs/statements/or-attire/. Published February 27, 2018. Accessed March 28, 2023. [Google Scholar]
- 276.Moehring RW, Anderson DJ. “But my patients are different!”: risk adjustment in 2012 and beyond. Infect Control Hosp Epidemiol 2011;32:987–989. [DOI] [PubMed] [Google Scholar]
- 277.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 1991;91:152S–157S. [DOI] [PubMed] [Google Scholar]
- 278.Malpiedi PJ, Peterson KD, Soe MM, Edwards JR, Scott RD II. National and state healthcare-associated infection standardized infection ratio report. Centers for Disease Control and Prevention; website. http://www.cdc.gov/hai/pdfs/SIR/SIR-Report_02_07_2013.pdf. Published May 13, 2013. Accessed March 28, 2023. [Google Scholar]
- 279.Mu Y, Edwards JR, Horan TC, Berrios-Torres SI, Fridkin SK. Improving risk-adjusted measures of surgical site infection for the national healthcare safety network. Infect Control Hosp Epidemiol 2011;32:970–986. [DOI] [PubMed] [Google Scholar]
- 280.Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the CDC experience. Jt Comm J Qual Improv 1996;22:457–467. [DOI] [PubMed] [Google Scholar]
- 281.Consensus paper on the surveillance of surgical wound infections: the Society for Hospital Epidemiology of America, the Association for Practitioners in Infection Control, the Centers for Disease Control, and the Surgical Infection Society. Infect Control Hosp Epidemiol 1992;13:599–605. [PubMed] [Google Scholar]
- 282.Berrios-Torres SI, Mu Y, Edwards JR, Horan TC, Fridkin SK. Improved risk adjustment in public reporting: coronary artery bypass graft surgical site infections. Infect Control Hosp Epidemiol 2012;33:463–469. [DOI] [PubMed] [Google Scholar]
- 283.Calderwood MS, Kleinman K, Soumerai SB, et al. Impact of Medicare’s payment policy on mediastinitis following coronary artery bypass graft surgery in US hospitals. Infect Control Hosp Epidemiol 2014;35:144–151. [DOI] [PubMed] [Google Scholar]
- 284.Masnick M, Morgan DJ, Sorkin JD, et al. Lack of patient understanding of hospital-acquired infection data published on the Centers for Medicare and Medicaid Services hospital compare website. Infect Control Hosp Epidemiol 2016;37:182–187. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 285.Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005;26:210–212. [DOI] [PubMed] [Google Scholar]
- 286.McKibben L, Horan T, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control 2005;33:217–226. [DOI] [PubMed] [Google Scholar]
- 287.Talbot TR, Bratzler DW, Carrico RM, et al. Public reporting of healthcare-associated surveillance data: recommendations from the healthcare infection control practices advisory committee. Ann Intern Med 2013;159:631–635. [DOI] [PubMed] [Google Scholar]
- 288.National voluntary consensus standards for the reporting of healthcare-associated infections data. National Quality Forum; website. http://www.qualityforum.org/Publications/2008/03/National_Voluntary_Consensus_Standards_for_the_Reporting_of_Healthcare-Associated_Infection_Data.aspx. Published January 6, 2013. Accessed March 28, 2023. [Google Scholar]
- 289.Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals’ FTE resident caps for graduate medical education payment. Final rules. Fed Register 2011;76:51476–51846. [PubMed] [Google Scholar]
- 290.Anthony T, Murray BW, Sum-Ping JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg 2011;146:263–269. [DOI] [PubMed] [Google Scholar]
- 291.Centers for Medicare & Medicaid Services. Operational guidance for reporting surgical site infection (SSI) data to CDC NHSN for the purpose of fulfilling CMS Hospital Inpatient Quality Reporting (IQR) program requirements. Centers for Disease Control and Prevention; website. https://www.cdc.gov/nhsn/pdfs/cms/ssi/Final-ACH-SSI-Guidance.pdf. Published November 2019. Accessed March 28, 2023. [Google Scholar]
- 292.Quality and patient safety resources. Agency for Healthcare Research and Quality; website. https://www.ahrq.gov/patient-safety/resources/index.html#projects. Updated December 2022. Accessed March 28, 2023. [Google Scholar]
- 293.Harris JA, Sammarco AG, Swenson CW, et al. Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan. Am J Obstet Gynecol 2017;216:502.e1–.e11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 294.Young H, Knepper B, Vigil C, Miller A, Carey JC, Price CS. Sustained reduction in surgical site infection after abdominal hysterectomy. Surg Infect (Larchmt) 2013;14:460–463. [DOI] [PubMed] [Google Scholar]
- 295.Glotzbecker M, Troy M, Miller P, Berry J, Cohen L, Gryzwna A, et al. Implementing a multidisciplinary clinical pathway can reduce the deep surgical site infection rate after posterior spinal fusion in high-risk patients. Spine Deform 2019;7:33–39. [DOI] [PubMed] [Google Scholar]
- 296.Gorgun E, Rencuzogullari A, Ozben V, et al. An effective bundled approach reduces surgical site infections in a high-outlier colorectal unit. Dis Colon Rectum 2018;61:89–98. [DOI] [PubMed] [Google Scholar]
- 297.Kaplan HC, Brady PW, Dritz MC, et al. The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q 2010;88:500–559. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 298.Tomoaia-Cotisel A, Scammon DL, Waitzman NJ, et al. Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change. Ann Fam Med 2013;11 suppl 1:S115–123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 299.Hsu CD, Cohn I, Caban R. Reduction and sustainability of cesarean section surgical site infection: an evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program. Am J Infect Control 2016;44:1315–1320. [DOI] [PubMed] [Google Scholar]
- 300.Hewitt DB, Tannouri SS, Burkhart RA, et al. Reducing colorectal surgical site infections: a novel, resident-driven, quality initiative. Am J Surg 2017;213:36–42. [DOI] [PubMed] [Google Scholar]
- 301.Lippitt MH, Fairbairn MG, Matsuno R, et al. Outcomes associated with a five-point surgical site infection prevention bundle in women undergoing surgery for ovarian cancer. Obstet Gynecol 2017;130:756–764. [DOI] [PubMed] [Google Scholar]
- 302.Parizh D, Ascher E, Raza Rizvi SA, Hingorani A, Amaturo M, Johnson E. Quality improvement initiative: preventative surgical site infection protocol in vascular surgery. Vascular 2018;26:47–53. [DOI] [PubMed] [Google Scholar]
- 303.Wright JG. Reducing surgical site infections in a children’s hospital: the fuzzy elements of change. J Clin Outcomes Manage 2016;23:157–163. [Google Scholar]
- 304.Forrester JA, Koritsanszky LA, Amenu D, et al. Developing process maps as a tool for a surgical infection prevention quality improvement initiative in resource-constrained settings. J Am Coll Surg 2018;226:1103–1116. [DOI] [PubMed] [Google Scholar]
- 305.Fisher JC, Godfried DH, Lighter-Fisher J, et al. A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance. J Pediatr Surg 2016;51:1030–1033. [DOI] [PubMed] [Google Scholar]
- 306.Schwann NM, Bretz KA, Eid S, et al. Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome. Anesth Analg 2011;113:869–876. [DOI] [PubMed] [Google Scholar]
- 307.Andiman SE, Xu X, Boyce JM, et al. Decreased surgical site infection rate in hysterectomy: effect of a gynecology-specific bundle. Obstet Gynecol 2018;131:991–999. [DOI] [PubMed] [Google Scholar]
- 308.Agarwal N, Agarwal P, Querry A, et al. Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery. J Neurosurg Spine 2018;29:108–114. [DOI] [PubMed] [Google Scholar]
- 309.Cassir N, De La Rosa S, Melot A, et al. Risk factors for surgical site infections after neurosurgery: a focus on the postoperative period. Am J Infect Control 2015;43:1288–1291. [DOI] [PubMed] [Google Scholar]
- 310.Hoang SC, Klipfel AA, Roth LA, Vrees M, Schechter S, Shah N. Colon and rectal surgery surgical site infection reduction bundle: to improve is to change. Am J Surg 2019;217:40–45. [DOI] [PubMed] [Google Scholar]
- 311.Ceppa EP, Pitt HA, House MG, et al. Reducing surgical site infections in hepatopancreatobiliary surgery. HPB (Oxford) 2013;15:384–391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 312.Abbas M, de Kraker MEA, Aghayev E, et al. Impact of participation in a surgical site infection surveillance network: results from a large international cohort study. J Hosp Infect 2019;102:267–276. [DOI] [PubMed] [Google Scholar]
- 313.Waits SA, Fritze D, Banerjee M, et al. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 2014;155:602–606. [DOI] [PubMed] [Google Scholar]
- 314.Lyren A, Brilli RJ, Zieker K, Marino M, Muething S, Sharek PJ. Children’s hospitals’ solutions for patient safety collaborative impact on hospital-acquired harm. Pediatrics 2017;140. [DOI] [PubMed] [Google Scholar]
- 315.Benlice CGE. Using NSQIP data for quality improvement: the Cleveland Clinic SSI experience. Semin Colon Rectal Surg 2016;27:74–82. [Google Scholar]
- 316.Lin DM, Carson KA, Lubomski LH, Wick EC, Pham JC. Statewide collaborative to reduce surgical site infections: results of the hawaii surgical unit-based safety program. J Am Coll Surg 2018;227:189–197. [DOI] [PubMed] [Google Scholar]
- 317.Willis ZI, Duggan EM, Bucher BT, et al. Effect of a clinical practice guideline for pediatric complicated appendicitis. JAMA Surg 2016;151:e160194. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 318.Riley MM, Suda D, Tabsh K, Flood A, Pegues DA. Reduction of surgical site infections in low transverse cesarean section at a university hospital. Am J Infect Control 2012;40:820–825. [DOI] [PubMed] [Google Scholar]
- 319.Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg 2012;215:193–200. [DOI] [PubMed] [Google Scholar]
- 320.Zhou L, Ma J, Gao J, Chen S, Bao J. Optimizing prophylactic antibiotic practice for cardiothoracic surgery by pharmacists’ effects. Medicine (Baltimore) 2016;95:e2753. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 321.Bogun M. Positive influence of weekly diabetes workshops for healthcare providers managing patients recovering after coronary artery bypass graft surgery (CABG): its potential role in reducing the surgical site infections. Diabetes 2017;66 suppl 1:A174. [Google Scholar]
- 322.Johnson MP, Kim SJ, Langstraat CL, et al. Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery. Obstet Gynecol 2016;127:1135–1144. [DOI] [PubMed] [Google Scholar]
- 323.Kapadia BH, Cherian JJ, Issa K, Jagannathan S, Daley JA, Mont MA. Patient compliance with preoperative disinfection protocols for lower extremity total joint arthroplasty. Surg Technol Int 2015;26:351–354. [PubMed] [Google Scholar]
- 324.Schaffzin JK, Mangeot C, Sucharew H, Beck AF, Sturm PF. Factors affecting adherence to a preoperative surgical site infection prevention protocol. Infect Control Hosp Epidemiol 2016;37:728–730. [DOI] [PubMed] [Google Scholar]
- 325.Eskildsen SM, Moskal PT, Laux J, Del Gaizo DJ. The effect of a door alarm on operating room traffic during total joint arthroplasty. Orthopedics 2017;40:e1081–e1085. [DOI] [PubMed] [Google Scholar]
- 326.Ehrenfeld JM, Wanderer JP, Terekhov M, Rothman BS, Sandberg WS. A perioperative systems design to improve intraoperative glucose monitoring is associated with a reduction in surgical site infections in a diabetic patient population. Anesthesiology 2017;126:431–440. [DOI] [PubMed] [Google Scholar]
- 327.O’Sullivan CT, Rogers WK, Ackman M, Goto M, Hoff BM. Implementation of a multifaceted program to sustainably improve appropriate intraoperative antibiotic redosing. Am J Infect Control 2019;47:74–77. [DOI] [PubMed] [Google Scholar]
- 328.Koek MBG, Hopmans TEM, Soetens LC, et al. Adhering to a national surgical care bundle reduces the risk of surgical site infections. PLoS One 2017;12:e0184200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 329.Roth B, Neuenschwander R, Brill F, et al. Effect of antiseptic irrigation on infection rates of traumatic soft tissue wounds: a longitudinal cohort study. J Wound Care 2017;26:79–87. [DOI] [PubMed] [Google Scholar]
- 330.Wathen C, Kshettry VR, Krishnaney A, et al. The association between operating room personnel and turnover with surgical site infection in more than 12,000 neurosurgical cases. Neurosurgery 2016;79:889–894. [DOI] [PubMed] [Google Scholar]
- 331.Grant MC, Hanna A, Benson A, et al. Dedicated operating room teams and clinical outcomes in an enhanced recovery after surgery pathway for colorectal surgery. J Am Coll Surg 2018;226:267–276. [DOI] [PubMed] [Google Scholar]
- 332.Lepanluoma M, Rahi M, Takala R, Loyttyniemi E, Ikonen TS. Analysis of neurosurgical reoperations: use of a surgical checklist and reduction of infection-related and preventable complication-related reoperations. J Neurosurg 2015;123:145–152. [DOI] [PubMed] [Google Scholar]
- 333.Tvedt C, Sjetne IS, Helgeland J, Lower HL, Bukholm G. Nurses’ reports of staffing adequacy and surgical site infections: a cross-sectional multicentre study. Int J Nurs Stud 2017;75:58–64. [DOI] [PubMed] [Google Scholar]
- 334.Pop-Vicas AE, Keating JA, Heise C, Carayon P, Safdar N. Gaining momentum in colorectal surgical site infection reduction through a human factors engineering approach. Infect Control Hosp Epidemiol 2021;42:893–895. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 335.Wadhwa A, Kabon B, Fleischmann E, Kurz A, Sessler DI. Supplemental postoperative oxygen does not reduce surgical site infection and major healing-related complications from bariatric surgery in morbidly obese patients: a randomized, blinded trial. Anesth Analg 2014;119:357–365. [DOI] [PubMed] [Google Scholar]
- 336.Thompson KM, Oldenburg WA, Deschamps C, Rupp WC, Smith CD. Chasing zero: the drive to eliminate surgical site infections. Ann Surg 2011;254:430–436. [DOI] [PubMed] [Google Scholar]
- 337.Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large-scale knowledge translation. BMJ 2008;337:a1714. [DOI] [PubMed] [Google Scholar]
- 338.Hranjec T, Swenson BR, Sawyer RG. Surgical site infection prevention: how we do it. Surg Infect (Larchmt) 2010;11:289–294. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 339.Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924–926. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 340.GRADE 2013. Canadian Task Force on Preventive Health Care website. http://canadiantaskforce.ca/methods/grade/. Published December 31, 2013. Accessed March 28, 2023.
- 341.Kaye KS, Schmit K, Pieper C, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis 2005;191:1056–1062. [DOI] [PubMed] [Google Scholar]
- 342.Pessaux P, Msika S, Atalla D, et al. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4,718 patients. Arch Surg 2003;138:314–324. [DOI] [PubMed] [Google Scholar]
- 343.Raymond DP, Pelletier SJ, Crabtree TD, Schulman AM, Pruett TL, Sawyer RG. Surgical infection and the aging population. Am Surg 2001;67:827–832. [PubMed] [Google Scholar]
- 344.Faraday N, Rock P, Lin EE, et al. Past history of skin infection and risk of surgical site infection after elective surgery. Ann Surg 2013;257:150–154. [DOI] [PubMed] [Google Scholar]
- 345.de Vries FEE, Atema JJ, Lapid O, Obdeijn MC, Boermeester MA. Closed incision prophylactic negative pressure wound therapy in patients undergoing major complex abdominal wall repair. Hernia 2017;21:583–589. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 346.Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750–756. [PubMed] [Google Scholar]
- 347.Hawn MT, Houston TK, Campagna EJ, et al. The attributable risk of smoking on surgical complications. Ann Surg 2011;254:914–920. [DOI] [PubMed] [Google Scholar]
- 348.Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 2003;85:178–181. [DOI] [PubMed] [Google Scholar]
- 349.Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002;359:114–117. [DOI] [PubMed] [Google Scholar]
- 350.Sharma A, Deeb AP, Iannuzzi JC, Rickles AS, Monson JR, Fleming FJ. Tobacco smoking and postoperative outcomes after colorectal surgery. Ann Surg 2013;258:296–300. [DOI] [PubMed] [Google Scholar]
- 351.Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Control 2006;15:352–358. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 352.Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg 2010;252:325–329. [DOI] [PubMed] [Google Scholar]
- 353.Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019;68:e83–e110. [DOI] [PubMed] [Google Scholar]
- 354.Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee. Guideline for hand hygiene in healthcare settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep 2002;51(RR-16):1–45. [PubMed] [Google Scholar]
- 355.Ford CD, VanMoorleghem G, Menlove RL. Blood transfusions and postoperative wound infection. Surgery 1993;113:603–607. [PubMed] [Google Scholar]
- 356.Horvath KA, Acker MA, Chang H, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg 2013;95:2194–2201. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 357.Olsen MA, Lock-Buckley P, Hopkins D, Polish LB, Sundt TM, Fraser VJ. The risk factors for deep and superficial chest surgical-site infections after coronary artery bypass graft surgery are different. J Thorac Cardiovasc Surg 2002;124:136–145. [DOI] [PubMed] [Google Scholar]
- 358.Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg 2011;253:1082–1093. [DOI] [PubMed] [Google Scholar]
- 359.Guidelines—ANSI/ASHRAE/ASHE standard 170: ventilation of healthcare facilities, 2010. Facility Guidelines Institute; website. http://www.fgiguidelines.org/guidelines2010.php. Published February 2, 2013. Accessed March 28, 2023. [Google Scholar]
- 360.Change in terminology and update of survey and certification (S&C) memorandum 09-55 regarding immediate use steam sterilization (IUSS) in surgical settings. Centers for Medicare and Medicaid Services; website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-14-44. Published 2014. Accessed March 2023. [Google Scholar]
- 361.Condition of participation: Infection prevention and control and antibiotic stewardship programs. §482.42. Centers for Medicare and Medicaid Services; website. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.42. Published 2021. Accessed March 2023. [Google Scholar]
- 362.Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–608. [PubMed] [Google Scholar]