Prevention of surgical site infection: still an important challenge in colorectal surgery.

Abstract

Surgical site infection (SSI) is the most frequent hospitalacquired infection after colorectal surgery. It has an important impact on postoperative hospital stay, mortality, readmission and overall healthcare costs. In the USA, SSI increases the cost of a colectomy by $17 324, on average [1]. More and more, SSI is related to the quality of care and several health insurances have ceased reimbursements for additional care provided because of SSI. Moreover, hospital administrators, legislators and politicians have also become aware of the adverse impact of SSI and of the fact that, in many cases, SSI are preventable. Benchmarking results have been shown to have a global improvement effect in specific group outcomes. However, there is still a wide variation in state monitoring and reporting SSI rates [2]. In the literature, SSI rates after elective colorectal surgery range from 5 to 40 % [3]. There seem to be two main reasons for this wide variation. On the one hand, different definitions, which are often very subjective, are used to diagnose infections. On the other hand, cases diagnosed after discharge and within 30 days after surgery are sometimes included, sometimes not. Most of the published series report SSI rates higher than expected according to the National Nosocomial Infections Surveillance (NNIS) report which raises the question of whether the NNIS reflects the overall reality of infection in colorectal surgery. Collaboration with cancer nurses may improve a strict follow-up and the increasing home care services may give patients an easier access to their surgical team in order to improve the completeness and reliability of registered data. Most of the studies on SSI after colorectal surgery analyze together colon and rectal operations as well as benign and malignant diseases. Other studies suggest that SSI rates and risk factors in colon surgery differ from those in rectal surgery. In rectal cancer surgery, there is often need for an ostomy, preoperative chemoradiation, anastomosis close to the anal verge, intersphincteric resections, ultra-low Hartmann procedures or abdominoperineal resections. Wound infection and organ space infection have been grouped together in the concept of SSI. However, these are two distinct scenarios that arise for different reasons and they should be evaluated separately. It has been observed that while tumor stage and conversion from laparoscopic to open surgery can influence wound infection, type of surgery influences organ space infection [4]. Risk factors for SSI have been identified. Patient-related factors (diabetes mellitus, malignancy, steroid use, anemia, need for perioperative blood transfusion, obesity and inmunosupression) or surgery-related factors (perioperative normothermia, hypoxia, bowel preparation, operative time, antibiotic prophylaxis, types of operation or wound edge protection) could influence the postoperative SSI rate. Despite the well-established beneficial effect of systemic antibiotic prophylaxis on SSI and the widespread use of prophylactic measures, the appropriateness of those measures is not clearly established. A recent randomized trial failed to prove that an evidence-based intervention bundle for preventing surgical site infection reduces SSI [5]. Another randomized trial in patients undergoing elective colorectal cancer surgery S. Biondo (&) Colorectal Unit, Department of General and Digestive Surgery, Bellvitge University Hospital, University of Barcelona, and IDIBELL, C/Feixa Llarga s/n, L’Hospitalet de Llobregat, 08907 Barcelona, Spain e-mail: sbn.biondo@gmail.com