Cross section of abdominal wall depicting CDC classification of surgical site infection 
Diagnosis of surgical site infections can be very challenging but is crucial in dictating the ultimate treatment regimen. Most ITP infections present with fever, localized tenderness/pain at the site, swelling, purulent discharge, and erythema at the site. More devastating complications of CSF infections present similarly to our patient with fevers, chills, nausea/vomiting, nuchal rigidity, and headache.
A superficial incisional SSI  must meet several diagnostic criteria: the infection must occur within 30 days of the procedure and involve the skin or subcutaneous tissue around the incision. Additionally, the patient must present with at least one of the following criteria: purulent drainage from the incision, organisms isolated from an aseptically obtained culture of fluid or tissue from the incision, at least one sign/symptom of an infection (pain or tenderness, localized swelling, redness, or heat—and the incision is deliberately opened by a surgeon—unless the culture is negative), or diagnosis of superficial incisional SSI by a surgeon or attending physician.
Diagnostic criteria for deep incisional SSI include the following signs and symptoms: infection within 30 days of the procedure (or 1 year with an implant) and involvement of the deep soft tissue (fascia/muscle), with an infection that must be related to the procedure. Additionally, the patient must present with at least one of the following signs: purulent drainage from the incision, a spontaneously dehiscent deep incision (or is deliberately opened by a surgeon when the patient has at least one of the following signs: fever >38 °C, localized pain, or tenderness—unless the culture is negative), evidence of an abscess or other forms of infection involving the incision on direct examination or by histopathologic/radiological examination, or diagnosis of a deep incisional SSI by a surgeon or attending physician. Table 28.1  includes the diagnostic criteria for superficial and deep surgical site infections.
Diagnostic criteria for superficial site infections (SSI), modified from 
Superficial incisional surgical site infections must meet the following two criteria:
• Occur within 30 days of the procedure
• Involve only the skin or subcutaneous tissue around the incision
At least one of the following:
• Purulent drainage from the incision
• Organisms isolated from aseptically obtained culture of fluid or tissue from the incision
• At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat—and the incision is deliberately opened by the surgeon—unless the culture is negative
• Diagnosis of superficial SSI by surgeon or attending physician
The following are not considered superficial SSI:
• Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration) or infected burn wounds
Deep incisional surgical site infections must meet the following three criteria:
• Occur within 30 days of the procedure (or 1 year in the case of implants)
• Are related to the procedure
• Involve deep soft tissues, such as the fascia and muscles
At least one of the following criteria:
• Purulent drainage from the incision but not from the organ/space of the surgical site
• A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following: fever (>38 °), localized pain, or tenderness—unless culture is negative
• An abscess or other evidence of infection involving the incision is found on direct examination or histopathologic or radiographical exam
• Diagnosis of deep SSI by a surgeon or attending physician
An organ/space SSI must meet the following criterion:
• Infection within 30 days after the operation procedure if no implant is left in place or within 1 year if an implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, which is opened or manipulated during the operative procedure, and patient has at least one of the following:
– Purulent drainage from the drain that is placed through a stab wound into the organ/space
– Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic
The primary pathogens of SSI for clean procedures are Staphylococcus aureus and coagulase-negative staphylococci (Staphylococcus epidermidis) .
In clean-contaminated procedures, gram-negative rods and enterococci must be accounted for, in addition to skin flora. The CDC is reporting more cases of antimicrobial-resistant pathogens such as methicillin-resistant S. aureus (MRSA)  or by fungal SSI. MRSA infections are associated with higher mortality rates, longer hospital stays, and higher hospital costs compared with other infections . ITPs are often classified under neurosurgical procedures where the primary infectious pathogen is Staphylococcus aureus , similar to intraventricular shunts.
The presence of these pathogens in the surgical site depends on several factors: the dose of bacterial contamination, the virulence of the pathogen, and the resistance of the host :
Patients are considered to be at increased risk of SSI if the surgical site is contaminated with >1,000,000 microorganisms per gram of tissue and no foreign material is implanted (significantly lower quantities can cause a SSI if foreign material is implanted). For most patients, the source of the SSI is their native flora on skin or mucous membranes . However, surgical personnel, operating room environment, instruments, or prosthetics can serve as exogenous sources of microbes.
28.3.1 Preoperative Precautions: Patient Optimization, Skin Preparation Prior to Incision, and Perioperative Antibiotics
188.8.131.52 Identification of Risk Factors for SSI
Patients with diabetes, nicotine use, chronic steroid use, malnutrition, prolonged preoperative hospital stay, preoperative colonization with Staphylococcus aureus, immunocompromised states (HIV, chemotherapy), and perioperative transfusion are considered to be at a higher risk for SSI (Table 28.2) .
Selected risk factor and recommendations to prevent surgical site infections (SSI), modified from 
Quality of evidence
Intrinsic, patient related (preoperative)
No formal recommendation to increase risk of SSI may be secondary to comorbidities or immune-senescence
History of radiation
No formal recommendation. Prior irradiation at surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia
History of skin/soft infection
No formal recommendation. History of prior skin infection may be a marker for inherent in host immune function
Control serum blood glucose levels for all surgical patients, including patients without diabetes. For patients with diabetes, reduce glycosylated HA1c to less than 7% before surgery if possible
Increase dosing of prophylactic antimicrobial agent for morbidly obese patients
Encourage smoking cessation within 30 days of the procedure
Immunosuppressive meds, hypoalbuminemia
No formal recommendation. Although noted risk factor does not delay surgery for use of TPN
Extrinsic, procedure related (perioperative)
Preparation of patient
Do not remove unless hair will interfere with the operation. If hair removal is necessary, remove outside the OR by clipping. Do not use razor
Identify and treat infections (e.g., urinary tract infections) remote to the surgical site prior to elective surgery. Do not routinely treat colonization or contamination
Surgical scrub (surgical team hands/forearm)
Use appropriate antiseptic agent to perform preoperative surgical scrub. For most products, scrub the hands and forearm for 2–5 min
Wash and clean skin incision site. Use a dual agent skin preparation containing alcohol, unless contraindications exist
Antimicrobial prophylaxis timing
Administer only when indicated
Blood transfusions increase the risk of SSI by decreasing macrophage function. Reduce blood loss and need for blood transfusion to greatest extent possible
Duration of prophylaxis
Stop agents within 24 h after the procedure for all procedures
Handle tissue carefully and eradicate dead space
Adhere to standard principles of OR sepsis
No formal recommendation in most recent guidelines. Minimize as much as possible without sacrificing surgical technique and aseptic practice
All members of the operative team should double glove and change gloves when perforation is noted
Choice of prophylactic agent
Select appropriate agents on the basis of surgical procedure, most common pathogens causing SSI for a specific procedure and published recommendations
Follow American Institute of Architects recommendations of proper air handling in OR
Minimize OR traffic
Use an EPA-approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment
Sterilization of surgical equipment
Sterilize all surgical equipment according to published guidelines. Minimize the use of immediate-use steam sterilization
Diabetics need strict glucose control, with HbA1c less than 8 within 30 days of the trial. Nicotine use affects wound healing and should be discontinued at least 30 days prior to surgery. Patients with poor nutritional status, as exemplified by poor caloric intake, poor protein rich diets, and low albumin levels, will also increase the risk of site infections . Some studies have correlated chronic steroid use (as in Crohn’s patient) with an increased risk of SSI (12.5% infection in patients using steroids vs. 6.7% in patients who are not on chronic steroid use) . Patients at risk for MRSA colonization should have a preoperative nasal swab and be treated appropriately in the perioperative period.
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28.4 Skin Preparation Prior to Incision
Many interventions have been implemented to minimize the occurrence of SSI. Some surgeons require patients to shower with antiseptic solution to reduce the skin microbial counts prior to surgery. Two antiseptic agents are available: chlorhexidine (reduce colony counts ninefold) and povidone-iodine (reduce colony counts 1.3–1.9-fold). However, while the flora counts have been reduced, no studies have shown to reduce SSI rates .
Higher rates of SSI have been reported with preoperative shaving which can create cuts in the skin and can serve as foci for bacterial colonization. A study by Seropian et al.  reported a 5% increase in SSI in patients who had shaved prior to surgery when compared to those who did not have hair removed. Shaving immediately before the procedure was associated with a 3% SSI rate. Ultimately, any form of hair removal has been associated with increased risk of SSI. The current recommendation is the use of electrical clippers immediately prior to incision and ideally in the preoperative waiting area (prior to entering the operating room).
Many skin preparations are available in the operating room including iodophors, alcohol-containing products, and chlorhexidine gluconate. Alcohol-containing products are ideal as they are inexpensive, readily available, and rapid-acting skin antiseptic and have germicidal effects on bacteria, fungi, viruses, and spores. However, the flammability of the solution creates a hazard in the operating room. Chlorhexidine and iodophors have extensive antimicrobial activity, but chlorhexidine has shown greater reduction in hand flora when used for preoperative surgical scrub . Curiously, iodophors are deactivated by blood or serum proteins, whereas chlorhexidine is not. Ideally, a 2–5 min surgical scrub is recommended. Table 28.3  compares the effectiveness of different surgical scrubs.
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