Background
Location
An infection is an illness that happens when germs grow inside your body. Infections that happen where surgery was performed are called surgical site infections (SSIs). SSIs are rare after scheduled surgery (0.5–2%) and more common after emergency surgery (10–15%). They usually happen within 30 days of surgery. Your doctor may describe SSIs by where the infection is: superficial (skin level), deep (below the skin down to muscle), and organ-space (inside your body) (figure 1).
Figure 1. Diagram of surgical site infections (SSI) by depth. This drawing shows the different depths of SSIs. It also shows a cut or ‘incision’ from surgery with a skin staple at the top.
Prevention
The surgical team works to prevent SSI before, during, and after surgery by cleansing the skin with a germ-killing wash, using ‘sterile’ coverings (deep cleaned to be germ free), and giving germ-fighting medicine, called antibiotics, before the surgery starts. If the surgery is to treat an infection, antibiotics will continue for a longer time because surgery can spread germs to other areas. After surgery, the doctor will check your cut for signs of infection.
Symptoms
Symptoms (things you feel) as well as signs (things the doctor sees or measures) can tell the doctor you have an SSI. SSIs give the doctor clues such as redness around the cut, more pain than usual, white/tan oozing, or a bad smell (figure 2). Other clues include fever, low energy, not feeling hungry, and nausea. These things should be reported to the surgical team any time of day.
Figure 2. Superficial surgical site infection (SSI). This photo shows a recent cut or ‘incision’ after surgery closed with a stitch (in blue). There is much more redness around the cut than expected. This is often how a skin-level SSI looks.
What happens in the hospital/intensive care unit
Diagnosis
Finding an SSI starts with talking about the timing, symptoms, and signs of infection. Testing starts by measuring how fast your heart is beating, your blood pressure, and your temperature. These are called your ‘vital signs’. The cut is also checked for signs of infection. Blood tests also help find clues from germs to tell if it is an infection.
Pictures of the infected area might be taken with tests called an ‘ultrasound’ or a ‘CT scan (Computed Tomography scan)’, also called a ‘CAT scan’. You may drink or be injected with a special dye. The dye helps your organs look different from infections or abscesses.
Medical (non-surgical) options
Most SSIs are caused by germs called bacteria. If your SSI is at the skin level, it may be cured with medicine (antibiotics) alone. If your SSI is deeper, medicine may not be enough. Some fluid from the infection may be tested to find out what bacteria are present (cultures), and which antibiotics will kill them (sensitivity). Your antibiotics may change after your tests. If the infection is very serious you may need to stay in the intensive care unit.
Surgical options
If your SSI is deeper, it may need medicine and drainage. Drainage means making a small cut to let the infection drain out, getting rid of more germs than medicine alone. If there is a source of bacteria such as a hole in the intestine, then the source must also be repaired. This is called ‘source control’, which takes care of the infection and any source that caused it. If surgery is needed, the surgeon will put a drain where the infection was and perform any procedures required for source control.
For deep SSI, reopening your cut can be done in your hospital room with numbing medicine and pain medication. The open wound is filled with moist gauze (packing) that needs to be changed often. SSIs inside your body (organ-space) also need to be drained. A team called interventional radiology may take pictures with ultrasound, CT, or X-ray to place a small drain inside your body where the infection is. The drain connects to a bag or small bulb to hold the drainage.
Care after treatment
You will have a set date to stop taking your medicine. Depending on your infection and your other health problems, some treatments may be longer or require antibiotics through a special intravenous called a peripherally inserted central catheter after discharge. A visiting nurse may help you with your home antibiotics and can also teach patients how to give it to themselves.
If you have a drain, tracking the amount, type, and color of any fluid from the drain is important. This helps your doctor know when the drain can be taken out. If you have an open cut, you may need to keep ‘packing’ it until it heals or cover it with a special sponge attached to a vacuum machine (called ‘negative pressure wound therapy’ or a ‘wound VAC’).
Possible complications/issues
First, the germs that are making you sick can learn to defend themselves against your antibiotics (this is called ‘resistance’). If this happens, you may need to change medicines or take more. Second, your drain can get blocked. Switching the drain with a larger one can fix the problem. Third, you may have allergies to your medicine. A skin rash is an early warning sign, and the surgeon should be told right away if you see one. Fourth, antibiotics can kill good bacteria in the intestines and allow a bad one (Clostridium difficile) to overgrow. These bacteria make toxins that cause fever, diarrhea, and stomach pain. If you have diarrhea while taking antibiotics, make sure to tell the surgeon right away.
What happens next
Discharge care
Discharge instructions will list reasons to call a surgeon, medications to take, appointments to keep, and wound or drain care.
Wound care
If your cut is closed, wash it every day with soap and water. Open wounds should have the packing changed each day or more often as needed. VAC dressings are changed every 2–3 days. A visiting nurse can help with dressing changes, but many patients learn to do it on their own!
Diet
You can eat your usual foods after an SSI. Eating yogurt with probiotics helps replace good bacteria that antibiotics kill. Avoid alcohol while taking antibiotics.
Activity
You may need to move around and exercise less depending on what surgery you had and what medicines you are taking. Some medicines make it less safe to do certain activities, like driving. Talk to your doctor about your plans.
Reflections from a survivor/family
“Dressing changes were frustrating and hard at first. After a few days, they were much less painful and we developed a rhythm to washing the incision and changing the dressing.”
Resources
Acknowledgements
We gratefully acknowledge the patients and their family members who worked in partnership with us to diagnose and manage surgical site infections whenever and wherever they occurred.
The views and opinions advanced in this manuscript are those of the authors and do not represent the positions or official policies of the Veterans Health Affairs or the US federal government.
Funding Statement
The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.