Surgical site infections: a comprehensive review

Abstract

Surgical site infections (SSIs) represent a major public health challenge, contributing to increased morbidity, mortality, and healthcare costs worldwide. This paper presents a comprehensive review of the epidemiology, classification, risk factors, microbiological aspects, treatment modalities, and prevention strategies for SSIs, based on contemporary research and evidence-based practice protocols. An extensive literature review was conducted, synthesizing existing studies on SSIs. A comprehensive search was performed in PubMed, Embase, Cochrane Library, and guidelines from leading organizations such as the American College of Surgeons, the US Centers for Disease Control and Prevention, the World Health Organization, and the Infectious Diseases Society of America. Inclusion criteria encompassed peer-reviewed articles as well as American and European medical guidelines focusing on the epidemiology, risk factors, microbiology, treatment, and prevention of SSIs. The review adhered to the PECO (population, exposure, comparator, outcome) framework. Some of the most significant global concerns related to SSIs include antibiotic resistance and the contamination of surgical instruments, particularly in resource-poor settings. Trauma patients, especially those undergoing emergency procedures or sustaining open fractures, are at increased risk for SSIs due to the severity of their injuries and higher contamination risks. These findings underscore the importance of preventive measures, such as appropriate preoperative interventions, strict aseptic techniques, and proper antibiotic prophylaxis, in reducing SSI incidence and improving patient outcomes.

INTRODUCTION

Surgical site infections (SSIs) are infections that occur at the incision site within 30 days of surgery or within 1 year when an implant is involved [1]. These infections pose major challenges for healthcare worldwide, as they account for a significant percentage of hospital-acquired infections and impose additional risks and burdens on patients, healthcare infrastructure, and society at large [2]. For surgical patients, SSIs constitute the majority of nosocomial infections and account for approximately 20% of all hospital-acquired infections [3]. The global burden of SSIs is considerable, with higher rates in low- and middle-income countries due to limitations in resources, infrastructure, and challenges in implementing infection control measures [2]. Moreover, the growing issue of antimicrobial resistance further complicates SSI management, making infections more difficult to treat and emphasizing the need for preventive measures and judicious antibiotic use.

PECO FRAMEWORK

The PECO (population, exposure, comparator, outcome) framework was employed to systematically assess the key factors influencing SSIs.

• Population (P): Patients undergoing surgical procedures.

• Exposure (E): Risk factors contributing to SSIs (e.g., surgical techniques, patient comorbidities, hospital settings).

• Comparator (C): Standard infection control versus enhanced protocols.

• Outcome (O): Incidence, prevention, and management of SSIs.

EPIDEMIOLOGY OF SSIs

The incidence of SSIs varies from 1% to 30% depending on the type of surgical procedure and patient-related factors [4]. Of the estimated 157,500 SSI cases reported in the United States in 2018, approximately 8,205 resulted in death [5]. SSI-related deaths account for 11% of those observed in intensive care units, making them one of the leading causes of unplanned hospital readmissions after surgery [6]. Patients with SSIs typically experience hospital stays that are 10 to 11 days longer than those without infections [7]. These prolonged stays lead to increased resource utilization, including antibiotic treatment, wound care, and diagnostic testing, thereby raising healthcare costs [8].

In the American healthcare system alone, the annual economic burden of SSIs is estimated at US $3.3 billion, with global costs being even higher [2]. This financial burden encompasses both direct costs (extended hospital stays, treatments, diagnostic tests) and indirect costs (loss of productivity due to long-term recovery and potential disability).

Beyond the economic impact, SSIs lead to several adverse patient outcomes, including higher risk of intensive care unit admission, increased mortality risks (2 to 11 times greater), a fivefold elevated risk of readmission to the hospital, and extended periods of recovery and even possible disability. The high morbidity, mortality, and economic implications of SSIs underscore the critical need for effective preventive measures.

CLASSIFICATION OF SSIs

SSIs are classified based on the location and depth of the infection. The three primary classifications are superficial incisional SSIs, deep incisional SSIs, and organ/space SSIs.

Superficial incisional SSIs

Superficial incisional SSIs are the most common type, accounting for more than 50% of cases. They are confined to the skin and the adjacent subcutaneous tissues around the incision [6]. A diagnosis of superficial incisional SSI is made when one or more of the following criteria are met: (1) purulent discharge from the surgical site; (2) an organism isolated from a surgical site; (3) a clinical diagnosis of an SSI by the surgeon; and (4) intentional incision of the wound by the surgeon accompanied by at least one associated symptom such as swelling, erythema, pain, or warmth.

Deep incisional SSIs

Deep incisional SSIs extend deeper into the tissues beneath the incision, affecting the muscles and fascia surrounding the surgical site. Because they penetrate beyond superficial layers, they generally require more extensive treatment.

Organ/space SSIs

Organ/space SSIs are the least common yet most severe type. They involve infections that extend beyond the skin, muscle, and surrounding tissues, affecting organs or spaces between organs [9]. These infections may be indicated by the discharge of pus from a drain placed in a body space or by the formation of an abscess. Misdiagnosis or delayed diagnosis of these life-threatening infections often necessitates extensive surgical intervention or prolonged intravenous antibiotic therapy, resulting in long recovery times or debilitating illness.

RISK FACTORS FOR SSIs

Numerous factors can increase the risk of developing an SSI. These factors can be broadly categorized into three groups: patient-related, procedure-related, and external factors.

Patient-related factors

Individual patient characteristics significantly influence susceptibility to SSIs. Key patient-related risk factors include age, immunocompromised state, smoking, obesity, diabetes, malnutrition, hypovolemia, steroid use, previous infections, prolonged preoperative in-hospital stay, and poor preoperative skin antisepsis.

Age

Individuals over 65 years old are more susceptible to infection due to age-related immune dysfunction [10].

Immunocompromised state

Conditions such as HIV/AIDS increase the risk of SSIs, as a weakened immune system is less effective at fighting infections [11].

Smoking

Smoking impairs the healing process and compromises immune response, elevating the risk of SSIs and related complications [11].

Obesity

A higher body mass index predisposes patients to SSIs, likely due to poor blood circulation and increased tension on surgical wounds [11].

Diabetes

Poorly controlled diabetes reduces the immune system’s effectiveness, thereby increasing the risk of infection.

Malnutrition

Inadequate nutrition compromises immune function and delays wound healing, making infections more likely.

Hypovolemia

Low blood volume impedes the delivery of oxygen and nutrients to tissues, hindering infection control.

Steroid use

Long-term steroid therapy suppresses the immune system, raising the risk of infections.

Previous infections

Existing infections may spread to the surgical site, leading to SSIs.

Prolonged preoperative in-hospital stay

Extended hospital stays before surgery increase exposure to nosocomial infections [12].

Poor preoperative skin antisepsis

Poor skin hygiene can double the bacterial load on the skin, increasing the likelihood of intraoperative contamination.

Procedure-related factors

Risk factors related to the surgical procedure itself include surgery type, duration of surgery, open surgery, use of drains, presence of foreign material, improper hair removal, hypothermia, and abnormal fluid collection.

Surgery type

emergency and internal organ surgeries (clean-contaminated, contaminated, and dirty wounds) carry a higher risk of SSIs than clean surgeries due to contact with contaminated body sites and fluids [13].

Duration of surgery

Longer procedures increase the exposure time of the wound, thereby raising the risk of contamination.

Open surgery

Open procedures involve larger incisions and more tissue disruption, leading to a higher risk of SSIs compared to laparoscopic surgeries.

Use of drains

Surgical drains can provide a pathway for bacteria to enter the wound.

Presence of foreign material

Implants and prostheses increase the risk of infection.

Improper hair removal

Shaving near the surgical site with a razor may irritate the skin and increase infection risk; clippers are a safer alternative [14].

Hypothermia

Low body temperature during surgery can impair immune function and wound healing.

Abnormal fluid collection

Hematomas and seromas create an ideal environment for bacterial growth [15].

External factors

Extrinsic factors that predispose patients to SSIs include contamination of the surgical site, equipment, or personnel, sharpness of surgical instruments, inadequate operating room ventilation, and increased operating room traffic. Preventing these risk factors through proper patient preparation, adherence to aseptic techniques, appropriate antibiotic prophylaxis, and meticulous wound care is essential for reducing SSI rates and improving patient outcomes.

Contamination of the surgical site, equipment, or personnel

Inadequate sterilization or disinfection of instruments, the surgical environment, or personnel can introduce bacteria into the wound [16].

Sharpness of surgical instruments

Dull instruments may retain biological material even after sterilization, leading to contamination and SSIs [9].

Inadequate operating room ventilation

Poor ventilation increases the concentration of airborne bacteria, elevating the risk of wound contamination [11].

Increased operating room traffic

High traffic in and out of the operating room raises the likelihood of introducing contaminants [10].

MICROBIOLOGY OF SSIs

SSIs are most commonly caused by bacteria, although a variety of microorganisms may be involved. The type of surgery, the patient’s medical conditions, and local antibiotic resistance patterns are critical factors in determining the causative organisms in specific patients.

Common bacterial pathogens

The most frequently isolated bacteria in SSIs include Staphylococcus aureus (including methicillin-resistant S. aureus [MRSA]), Staphylococcus epidermidis, Streptococcus species, Pseudomonas aeruginosa, Escherichia coli, Enterococcus faecalis, Citrobacter freundii, and Bacillus cereus

S. aureus, including MRSA, is a major pathogen in SSIs, particularly in procedures involving the heart, breast, eyes, bones, and blood vessels. These organisms are difficult to treat because of their resistance to many commonly used antibiotics [10]. Coagulase-negative staphylococci such as S. epidermidis, which are part of the normal skin flora, account for most SSIs in clean surgical settings [10]. Gram-negative bacteria, notably P. aeruginosa and E. coli, are also frequently isolated in SSIs, especially in hospital settings; P. aeruginosa thrives in moist environments and is resistant to many antibiotic treatments [12].

Additionally, E. faecalis, a gut commensal with rising antibiotic resistance, has emerged as a cause of SSIs, particularly in abdominal and pelvic operations. C. freundii is an opportunistic pathogen that causes SSIs, mainly in hospitalized patients [12]. Although B. cereus is generally regarded as an environmental contaminant, it is increasingly recognized as a source of nosocomial infections, including SSIs. A study at Korle Bu Teaching Hospital in Ghana found that B. cereus was the predominant bacterium isolated from sterilized surgical instruments and related components [10].

Surgical instrument contamination

Even when proper sterilization techniques are applied, surgical instruments can become contaminated during operations, potentially leading to SSIs. Contamination may occur through contact with the patient’s skin flora or intestinal microbes [11]. In outbreaks of SSIs related to contaminated instruments, studies have shown that patient specimens, outer packaging, and the instruments themselves may harbor skin flora such as coagulase-negative staphylococci and Bacillus spp. A study on osteotome contamination demonstrated that all tested tools exhibited bone contaminants, although the extent varied with the presence of coatings [17]. These findings emphasize the importance of stringent sterilization protocols and highlight the risks associated with instrument contamination, particularly in resource-poor settings where protocols may not be rigorously followed.

TREATMENT OF SSIs

The treatment of SSIs depends on factors such as the type and severity of the infection, the causative microorganisms, and the patient’s overall health. It is important to note that the information provided herein is for general knowledge only and should not be construed as medical advice. The treatment of an SSI should be determined by a qualified healthcare provider based on the specific circumstances of the individual patient.

General treatment approaches

Treatment typically involves a combination of modalities, with the approach tailored to the severity of the infection. Common treatment strategies are as follows.

Antibiotics

Most SSIs are treated primarily with antibiotics. The choice of antibiotic is determined by the suspected or identified pathogen, the severity of the infection, and the patient’s medical history. When wounds discharge, cultures are taken and tested for sensitivity to identify the most effective antibiotic [1,2]. The treatment duration is based on the infection’s severity and the patient’s response, usually requiring at least one week of therapy. Patients often begin with intravenous antibiotics and transition to oral therapy as their condition improves. Completing the prescribed course is essential to eradicate the infection and prevent antibiotic resistance.

Surgical therapy

In cases involving significant pus collection, tissue necrosis, or foreign bodies, surgical intervention is required as an adjunct to antibiotic therapy. Surgical management may include the following: opening the wound to improve visualization, cleaning, and draining of the infected site; debridement to remove dead or infected tissue, which is essential for promoting healing (mechanical debridement is preferred, though enzymatic debridement may be considered if mechanical methods are contraindicated); irrigation with sterile saline to remove bacteria and debris; abscess drainage to clear infection if an abscess is present; and wound dressing with saline-soaked materials to maintain a moist environment that promotes healing.

Wound care

Regular cleaning, dressing changes, and in some cases, negative-pressure wound therapy (NPWT) or vacuum-assisted closure dressings, are essential for proper healing and preventing recurrence.

Supportive care

Supportive care includes optimizing the patient’s overall health through pain management, fluid and electrolyte balance, and nutritional support.

DM control for SSIs

Diabetes mellitus (DM) is a significant risk factor for SSIs because it has broad implications for immune response, vascular integrity, and wound healing. Uncontrolled hyperglycemia disrupts leukocyte function, slows collagen synthesis, promotes an environment favorable for bacterial growth, and increases the likelihood of postoperative infections. Maintaining intraoperative and perioperative blood glucose levels at 140 to 180 mg/dL and a hemoglobin A1c (HbA1c) of 7% to 8% is recommended by organizations such as the American Diabetes Association and the American Association of Clinical Endocrinologists. Continuous glucose monitoring can lead to improved postoperative outcomes [18].

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy (HBOT), which involves breathing pure oxygen in a pressurized environment (typically 2 to 3 atmospheres), enhances tissue oxygenation, promotes wound healing, and exhibits antimicrobial activity—particularly against anaerobic bacteria [19]. Under high pressure, HBOT increases oxygen diffusion and generates reactive oxygen species that have bactericidal effects on anaerobes like C. perfringens and B. fragilis [19,20]. Moreover, it enhances neutrophil activity, promotes fibroblast growth and angiogenesis, accelerates wound healing, and reduces inflammation and oxidative stress, all of which contribute to maintaining wound oxygenation and stimulating tissue repair, making it a valuable adjunct for treating complex or resistant SSIs [18,21].

Specific treatment considerations

Treatment strategies may be tailored based on the type of SSI and the causative organisms. Superficial incisional SSIs can usually be managed with wound care and oral antibiotics. Deep incisional SSIs might require surgical debridement and intravenous antibiotics. Organ/space SSIs typically require extensive surgical intervention, prolonged antibiotic therapy, and intensive care management.

Gram-positive bacteria

Gram-positive pathogens include S. aureus, including MRSA, and Enterococcus species. Therapeutic choices include β-lactams (cefazolin is the drug of choice for most SSIs; nevertheless, other β-lactams, such as ceftaroline and ceftobiprole, can be utilized for treating MRSA infections [16]), vancomycin (an alternative for patients who are allergic to β-lactams or in high MRSA-prevalence settings [14]), daptomycin (a lipopeptide antibiotic with a high level of activity against MRSA and other Gram-positive bacteria [20]), lipoglycopeptides (dalbavancin and oritavancin are two long-acting antibiotics that can be administered in single doses for some types of SSIs [3,11]), and linezolid (an oxazolidinone antibiotic that exerts wide-spectrum of activity against MRSA and other resistant Gram-positive bacteria).

Gram-negative bacteria

Gram-negative pathogens include E. coli, Klebsiella pneumoniae, and P. aeruginosa. The choice of therapy includes third-generation cephalosporins (SSIs due to susceptible Gram-negative bacteria are commonly treated with third-generation cephalosporins—namely, ceftriaxone and cefotaxime [21]), carbapenems (other broad-spectrum antibiotics comprise carbapenems like imipenem, meropenem, and doripenem, which are active against many Gram-negative bacteria; however, their use should be limited to critical cases because carbapenems can favor the development of resistance [22]), β-lactam/β-lactamase inhibitor combinations (include ceftazidime-avibactam, ceftolozane-tazobactam, and meropenem-vaborbactam which are effective against most resistant Gram-negative bacteria [23]), cefiderocol (a new siderophore cephalosporin that is active against a wide range of Gram-negative bacteria, including carbapenem-resistant strains [22]), tigecycline (a glycylcycline antibiotic that is active against most multidrug-resistant [MDR] Gram-negative bacteria [22]), and colistin (an older antibiotic reserved for infections caused by MDR Gram-negative bacteria that are resistant to other antibiotics [21]).

Other considerations

Combination therapy

For infections caused by MDR bacteria or to boost the effectiveness of a particular antibiotic, antibiotics can be administered in combination.

Duration of therapy

The duration of antibiotic therapy varies with the severity and type of SSI. Superficial SSIs may require only a few days of antibiotics, while deep or organ/space SSIs may require weeks or even months of treatment.

PREVENTION OF SSIs

Preventing SSIs is a primary objective in surgical care. Implementing evidence-based practices and adhering to established guidelines significantly reduce infection incidence and improve patient outcomes. The World Health Organization has published guidelines recommending 29 specific measures for SSI prevention [24]. Prevention strategies encompass preoperative, intraoperative, and postoperative interventions. Adherence to these comprehensive preventative measures contributes to a safer surgical experience and improved patient outcomes. Healthcare professionals play a critical role in educating patients about these measures and ensuring their consistent implementation.

Preoperative interventions

Preoperative measures aim to optimize patient health, reduce microbial burden, and establish a clean surgical environment.

Optimizing patient health

Optimizing patient health is a key preventive measure against SSIs. This includes smoking cessation, weight management, control of diabetes, addressing preexisting infections, and medication review [24–26]. Smoking significantly increases the risk of SSIs; quitting 6 to 8 weeks before surgery can improve wound healing and reduce infection risk. Although there is no universal body mass index (BMI) standard for surgery, a BMI of >35 kg/m² significantly increases the risk of SSIs due to higher levels of bacterial skin contamination, intertrigo, edema, and vascular disorders. Therefore, preoperative weight loss is recommended for obese patients through lifestyle modifications or medical interventions if necessary.

A correlation between diabetes control and SSIs has been well-established by various studies. According to the US Centers for Disease Control and Prevention guidelines, preoperative post-meal glycemia levels should be <200 mg/dL [24]. The American Diabetes Association recommends an HbA1c below 7%, pre-meal glucose of 80 to 130 mg/dL, and post-meal glucose below 180 mg/dL [27].

Addressing infections such as urinary tract or skin infections before surgery can also reduce the risk of developing SSIs. Additionally, medications that can suppress the immune system and increase infection risk, such as corticosteroids, should be carefully reviewed and adjusted as needed to minimize SSIs.

Reducing microbial burden

Preoperative intervention includes reducing microbial burden [28].

Preoperative hygiene

Patients should shower or bathe with an antiseptic solution (e.g., chlorhexidine) the night before and/or the morning of surgery to reduce skin bacteria.

Hair removal

When necessary, hair removal should be performed immediately before surgery using clippers rather than razors to avoid skin irritation and microabrasions.

Nasal decolonization

For high-risk procedures, such as cardiac or orthopedic surgeries, nasal screening for S. aureus (including MRSA) may be performed, and patients with positive results can be treated with intranasal mupirocin to reduce bacterial colonization.

Oral hygiene

Proper oral hygiene and professional dental cleaning before surgery can reduce the risk of SSIs, particularly in abdominal procedures.

Provision of a clean surgical environment

Another preoperative intervention is provision of a clean surgical environment [29].

Antibiotic prophylaxis

Administering appropriate antibiotics within 60 minutes before the surgical incision helps eliminate common pathogens that might cause SSIs. The choice of antibiotic depends on the type of surgery and patient risk factors.

Sterile technique

Maintaining strict sterile technique—including proper hand hygiene, the use of gloves and gowns, and careful handling of surgical instruments—is critical.

Environmental control

Optimizing operating room conditions, including ventilation and air filtration, reduces airborne bacteria and the risk of wound contamination.

Intraoperative measures

Intraoperative strategies focus on maintaining a sterile field and reducing the duration of surgery. Key measures are as follows. Strict adherence to sterile technique throughout the procedure, including proper hand hygiene, surgical attire, and aseptic handling of instruments. Reducing surgical time through efficient techniques and careful planning, as longer operations increase infection risk. Proper tissue handling to minimize trauma and reduce infection risk. Effective hemostasis to prevent the accumulation of blood and serum, which can serve as a medium for bacterial growth. Employing appropriate wound closure techniques with suitable suture material and tension to promote optimal healing and minimize infection risk.

Postoperative care

Postoperative care is essential for preventing SSIs and promoting wound healing. Key aspects include the following. Regular wound care involving cleaning, dressing changes, and monitoring for signs of infection. Effective pain management to ensure patient comfort and facilitate early ambulation. Early ambulation to improve blood circulation and reduce the risk of complications. Patient education on proper wound care and the recognition of infection signs, empowering them to seek timely medical attention if necessary.

TRAUMA-RELATED SSIs

Trauma patients are at increased risk for SSIs due to several factors, including emergency surgical interventions, high levels of wound contamination, and delayed definitive management.

Incidence of SSIs in trauma patients

In trauma patients, reported infection rates vary widely based on injury severity and the type of surgery, ranging from 2.5% to 41.9% worldwide. In the United States, SSIs account for approximately 17% of all hospital-acquired infections among surgical patients; for example, the reported SSI rate is 7.8% for tibial plateau fracture surgeries and ranges from 5% to 10% for vascular trauma surgery [30].

Among trauma patients, those with open fractures are particularly high-risk. Infection rates in Gustilo grade III open fractures have been reported to reach up to 53%, underscoring the critical importance of infection control in trauma surgery [31]. In contrast, an analysis from Poland reported SSI rates of 0.8% for open reduction of long bone fractures and 1% for closed reductions with internal fixation [32]. These variations underscore the need for standardized infection control procedures tailored to specific trauma settings.

Risk factors for SSIs in trauma patients

SSIs in trauma patients arise from factors such as injury severity, the patient’s overall condition, and various procedural variables. High-energy injuries—including gunshot wounds, blast trauma, and severe crash injuries—significantly elevate SSI risk due to extensive tissue damage, vascular destruction, and contamination [33]. For example, gunshot wounds often lead to deep, polymicrobial infections because of the presence of foreign debris and necrotic tissue. Similarly, stab wounds and low-energy penetrating injuries can pose serious risks due to potential deep tissue involvement or retained foreign bodies [34]. Open fractures, particularly Gustilo-Anderson type III and Cauchoix grade 3 fractures, are associated with infection rates exceeding 50%, with delayed definitive wound closure further increasing SSI risk [33].

In spinal trauma patients, SSI risk can exceed 10%. Factors that further increase the risk include longer surgical durations (exceeding 3 hours), delayed surgery (more than 72 hours after injury), significant blood loss (over 600 mL), and the fusion of more than three spinal levels. Posterior surgical approaches are more strongly associated with SSIs than anterior approaches, likely due to larger surgical fields and increased exposure. In addition, prolonged use of urinary catheters (over 5 days) and extended postoperative bed rest (more than 30 days) further elevate SSI risk in these patients [34].

Several host-related factors are also critical in determining SSI risk in trauma patients. For example, severe anemia reduces tissue oxygenation, thereby compromising immune function and wound healing [35]. Hyperglycemia—whether due to diabetes or a stress response—impairs leukocyte function, promoting bacterial growth. Moreover, immunosuppression resulting from sepsis, chronic steroid use, or cancer predisposes patients to nosocomial infections and MDR organisms (MDROs) [33].

Hospital and procedural factors also significantly impact SSI risk. External fixation devices, which are often required in high-energy fractures, can serve as portals for nosocomial colonization, markedly increasing infection risk [33]. Furthermore, polymicrobial infections are common, with Gram-positive cocci such as S. aureus predominating [34]. Repeated exposure to hospital-acquired pathogens, resulting from delayed wound closure and debridement, further extends the risk of infection [33].

Management and control strategies of SSIs in trauma patients

Effective management of SSIs in trauma patients requires early diagnosis, appropriate antimicrobial treatment, surgical debridement, and host optimization. Empirical broad-spectrum antibiotics should be initiated immediately, covering both Gram-positive and Gram-negative bacteria. For MRSA coverage, vancomycin or linezolid is recommended, while piperacillin-tazobactam or meropenem provides coverage for Gram-negative and anaerobic organisms. Once microbiological cultures identify the causative agents, antibiotic therapy should be narrowed to minimize the risk of resistance [34].

Surgical management is the cornerstone of treating trauma-related SSIs. Prompt and aggressive debridement removes necrotic tissue, biofilm, and foreign material, effectively reducing the microbial load. The use of antiseptic solutions such as povidone-iodine or chlorhexidine further decreases bacterial contamination [33]. NPWT is particularly beneficial for complex wounds and open fractures, as it reduces edema, promotes tissue healing, and lowers bacterial load [36].

In spinal trauma patients, managing infections is particularly challenging due to the proximity to neural structures. Early diagnosis relies on inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein, imaging studies (e.g., contrast-enhanced magnetic resonance imaging), and tissue cultures. While most infections can be managed with targeted antibiotic therapy without hardware removal, recurrent infections may require revision surgery. In severe cases, hardware removal is indicated, although this option is complicated by pseudoarthrosis and poor prognosis. Proper wound irrigation, meticulous hemostasis, and effective drain management are essential for preventing deep infections and optimizing outcomes [37].

Preventing SSIs in orthopedics and traumatology demands timely wound management, stringent perioperative infection control, and thorough postoperative surveillance. High-volume irrigation, meticulous debridement, and preoperative antibiotic prophylaxis administered within 1 hour of surgery have been shown to significantly reduce infection risk [38].

Strict perioperative procedures—such as maintaining normothermia, ensuring adequate oxygenation, controlling blood glucose levels, and screening for MDROs—further optimize immune function and promote wound healing. Measures including effective hemostasis, proper drain management, and intraoperative glove changes help reduce contamination, while a multidisciplinary infection control team oversees antibiotic stewardship and wound surveillance [39].

Educating patients about proper wound care and the early signs of infection helps reduce post-discharge complications. Additionally, proper postoperative dressing care is necessary, with guidelines recommending at least 24 to 48 hours of sterile dressing. Although the World Health Organization and the Asia Pacific Society of Infection Control do not advocate for the routine use of special dressings, the National Institute for Health and Care Excellence and the Royal College of Surgeons in Ireland recommend aseptic, noncontact dressing methods. When proper dressing procedures are followed, showering 12 to 48 hours after surgery does not increase the risk of SSIs [39].

GLOBAL IMPLICATIONS OF SSIs

The burden of SSIs is especially pronounced in resource-limited settings, where limited access to healthcare, inadequate infrastructure, and challenges in implementing infection control measures contribute to higher infection rates.

SSI rates in low- and middle-income countries

In low- and middle-income countries, the incidence of SSIs is considerably higher, with approximately 11% of surgical patients experiencing infections. In Africa, the rate reaches up to 20% among women undergoing caesarean sections [40]. These disparities are likely due to several factors: (1) lack of resources and infrastructure (insufficient healthcare infrastructure, including limited access to sterile supplies, clean water, and adequately trained healthcare personnel, contributes to higher infection rates); (2) challenges in implementing infection control measures (scarce resources and minimal training hinder the effective implementation of infection control protocols); and higher prevalence of underlying medical conditions (conditions such as malnutrition, HIV/AIDS, and other chronic illnesses increase susceptibility to infections).

Antimicrobial resistance

SSIs contribute to the growing global problem of antibiotic-resistant bacteria. As infection rates rise, so does the demand for antibiotics, which in turn selects for resistant strains and complicates treatment [41]. The occurrence and spread of antimicrobial resistance strengthen the case for the following: (1) prudent use of antibiotics (administering antibiotics only when necessary and ensuring patients complete the full course to prevent resistance); (2) antimicrobial stewardship programs (implementing hospital-based programs that focus on optimizing antibiotic use and preventing the spread of resistance); and (3) infection prevention and control (reducing infection rates through effective prevention strategies to minimize antibiotic usage and preserve their efficacy).

Surgical instrument contamination

Sterilization of surgical instruments is crucial for preventing SSIs, particularly in resource-limited settings. Despite established sterilization protocols, instruments can become contaminated during procedures, and studies have reported bacterial contamination even after sterilization. This necessitates stringent cleaning, disinfection, and sterilization processes (ensuring sterility by rigorously following reprocessing protocols for instruments); regular maintenance and quality control (monitoring the effectiveness of sterilization processes and maintaining equipment properly); and training and education (providing healthcare personnel with thorough training on sterilization techniques and infection control measures).

A multifaceted approach is required that includes strengthening infection control infrastructure, promoting judicious antibiotic use, optimizing patient care, and strict adherence to sterilization protocols. Continued research, education, and international collaboration are essential to develop and implement effective preventive strategies and mitigate the impact of antimicrobial resistance.

RESEARCH AND FUTURE DIRECTIONS

Further research is needed to improve the prevention and treatment of SSIs. Current and future research areas include the following: (1) new prevention methods (developing novel antiseptic solutions, innovative wound dressings, and improved surgical techniques to effectively prevent infections); (2) new treatments (creating new antibiotics and exploring alternative treatment modalities, such as antimicrobial photodynamic therapy and phage therapy, to address antibiotic resistance); (3) emerging pathogens and resistance (investigating newly discovered pathogens and monitoring the ongoing spread of antibiotic resistance to better guide prevention and treatment efforts); (4) instrument contamination (designing instruments with enhanced surface properties and researching new sterilization methods that minimize contamination); standardization of guidelines and best practices (establishing standardized guidelines for the prevention and management of SSIs, particularly in resource-poor settings); and international cooperation and knowledge sharing (promoting collaboration among researchers, clinicians, and healthcare organizations worldwide to advance efforts against SSIs).

The thematic outline derived from these sources offers a comprehensive framework for understanding the complexities of SSIs. This framework can further facilitate research, education, and the development of clinical practice guidelines. By addressing knowledge gaps and translating research findings into clinical practice, the global burden of SSIs can be reduced and patient outcomes improved.

CONCLUSIONS

SSIs are a significant complication of surgery and pose an ever-increasing threat to patient health and strain healthcare systems worldwide. A comprehensive understanding of the epidemiology, classification, risk factors, microbiology, treatment, and prevention of SSIs is essential for healthcare professionals to manage these infections effectively and improve patient outcomes. A multifaceted approach—including patient education, preoperative optimization, strict adherence to sterile techniques, appropriate antibiotic prophylaxis, and meticulous wound care—is critical in reducing SSI rates. Addressing the global burden of SSIs, particularly in resource-limited settings, requires a concerted effort to strengthen infection control infrastructure, promote judicious antibiotic use, and implement evidence-based preventive strategies. Ongoing research, innovation, and international collaboration are vital to advancing our understanding of SSIs, developing novel prevention and treatment strategies, and combating antimicrobial resistance.