Risk Of Postoperative Wound Infection Research Articles

Prevention and Treatment of Postsurgical Head and Neck Infections.

Postoperative wound infection is an important cause of postsurgical morbidity. Efforts to reduce the incidence of wound infection are enhanced through appropriate preoperative preparation, adherence to excellent surgical technique, and the provision of outstanding postoperative care. Many head and neck surgical procedures are undertaken in an environment contaminated by saliva containing a large inoculum of potentially pathogenic bacteria. Prospective randomized clinical trials have demonstrated that perioperative antibiotic prophylaxis reduces the risk for postoperative wound infection. Effective antibiotic prophylaxis requires that the antibiotic be effective against normal oral flora. Antibiotics should be administered before wound contamination. The dose of the antibiotic should exceed the minimal inhibitory concentration needed for the normal flora. The antibiotic administration can cease within 24 hours of surgery.

Does Reoperation Predispose to Postoperative Wound Infection in Women Undergoing Operation for Breast Cancer?

Reoperations for breast cancer predispose to a higher risk of postoperative wound infections than primary procedures. We accomplished a retrospective chart review of 320 women who underwent multiple breast cancer procedures between 10/97 and 8/02. The mean number of procedures was 2.4 (range, 2–5). The overall incidence of wound infection was 6.1 per cent. Wound infections developed, on average, 12 days after surgery (range, 2–30). There was a statistically significant difference in the incidence of wound infection comparing the initial procedure versus the subsequent operation (1.6% vs. 9.4%, P < 0.001). This was also seen with reoperation after an operative biopsy compared to operation after a core biopsy (11.1% vs. 9.7%, P < 0.01). The incidence was increased to 22.0 per cent when the initial operation involved lymph node dissection (sentinel lymph node biopsy or complete axillary lymph node dissection). Wire localization did not increase the incidence of postoperative wound infections, and prophylactic antibiotics were associated with a decreased incidence of wound infection in the reoperative setting. The incidence of wound infection is increased with reoperation after operative biopsy compared to operation after core biopsy and is further increased when the initial biopsy involved lymph node dissection.

A population-based study of surgery for spinal metastases. Survival rates and complications.

The management of spinal metastases is palliative and aimed at improving quality of life at an acceptable risk. This population study uses administrative databases and measures survivorship and complication rates after surgery for spinal metastases. The effects of various potential predictor variables were evaluated. We identified 987 patients with a median survival for all types of cancer of 227 days. The one and three-month mortality was 9% and 29%, respectively. Increasing age, male gender and primary lung cancer were significant risk factors for death within 30 days of surgery. A preoperative neurological deficit contributed a 19% increase in mortality and a 71% increase in the risk of postoperative wound infection. We found an overall major complication rate of 27%. This information will provide patients, families and clinicians with objective data which will help in the choice of treatment and the understanding of the surgical risk and outcome.

Antiseptic wound ventilation with a gas diffuser: a new intraoperative method to prevent surgical wound infection?

Postoperative wound infections are often a result of peri-operative contamination by Staphylococcus aureus. With a new insufflation device, a gas diffuser, it has become possible to establish a local micro-environment of almost 100% carbon dioxide in an open surgical wound. The device enables ventilation of the wound with an antiseptic agent, which in gaseous form can be delivered as a low uniform dose to all parts of the wound. The use of carbon dioxide (CO 2) as a carrier gas eliminates possible inflammability of an antiseptic agent and helps to concentrate it to the site of interest by gravity. Using the above delivery system we have demonstrated the antibacterial effect of gaseous ethanol on S. aureus inoculated on sterile filter disks and blood agar plates, respectively. Ethanol is a very potent antiseptic agent with known properties, which makes it suitable for testing the maximal decontamination level. On filter disks, CO 2 carrying vapour from a 95% ethanol solution decreased the number of colony-forming units after 5 min of exposure ( P=0.04), and killed all bacteria within 10–15 min ( P<0.001). In the presence of organic material, i.e. on exposed blood agar plates, the colony size decreased with exposure time, and no colonies were detected after 60 min of exposure ( P<0.001). Antiseptic gas derived from 70% ethanol solution was less effective than that from 95% ethanol ( P<0.001). CO 2 humidified with water did not have a significant effect on number or size of the colonies. Our findings suggest that intraoperative wound antisepsis with a gas mixture of CO 2 and an antiseptic agent delivered with a gas diffuser, may be a simple method to reduce the risk of postoperative wound infection.

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

Epidemiologic evaluation of postoperative wound infection in clean-contaminated wounds: A retrospective study of 239 dogs and cats.

To evaluate risk factors for development of postoperative wound infections in clean-contaminated wounds. Retrospective clinical study. Two hundred thirty-nine dogs and cats that had clean-contaminated surgical procedures. Records of animals that had a clean-contaminated surgical procedure and were prospectively monitored for development of postoperative wound infection were reviewed. Prospective data included signalment, nutritional status, body weight, duration of surgery, surgical procedures, wound classification, surgical site clip time before surgery, hypotension during surgery, the presence of an active distant infection, endocrinopathy, administration of an immunosuppressive agent, administration of antibiotics, and the type of antibiotic used. Additional retrieved data included total anesthesia time, temperature variables, blood loss, and suture material used. Intact males (P =.008) and animals with concurrent endocrinopathy (P =.008) were at a higher risk of development of postoperative wound infection. Total surgery time (P =.02) and total anesthesia time (P =.04) were longer in animals that developed postoperative wound infection. No other factors were statistically significant. Intact males and animals with a concurrent endocrinopathy were at higher risk of postoperative wound infection after clean-contaminated surgical procedures. Time under anesthesia and duration of surgery should be minimized to reduce the risk of wound infection in clean-contaminated surgical procedures.

Topical Perioperative Antibiotic Prophylaxis for Minor Clean Inguinal Surgery

In minor clean procedures, such as inguinal hernia repair and varicocelectomy, the efficacy of systemic perioperative antibiotic prophylaxis is not well established. To determine the efficacy of topical antibiotic prophylaxis alone in preventing postoperative wound infection in a minor urologic clean procedure, we retrospectively reviewed the medical records of 1,654 patients who had undergone microsurgical varicocelectomy. From September 1985 until December 2000, 1,654 men underwent 2,554 microsurgical varicocelectomies (900 bilateral) by a single surgeon (MG). The skin was shaved and then prepped with standard Betadine gel (Purdue Frederick) that was wiped away with 70% ethanol. No systemic antibiotics were used. The wound was irrigated with 1% neomycin at the moment the incision was made, and then every few minutes until the completion of the procedure, which averaged 45 minutes per side. No postoperative antibiotics were used. No wound infections occurred. No patient developed an adverse reaction to topical application of neomycin. One can conclude that the infection rate in this study is no higher than 0.2% with 95% confidence. Our review of a large series of consecutive clean urologic procedures indicates that by combining a skin preparation of Betadine gel and 70% ethanol with perioperative topical neomycin irrigation at the moment of skin incision, the risk of postoperative wound infection when performing microsurgical varicocelectomy can be effectively reduced to less than 0.2%.

Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients.

To examine the relationship between preoperative biliary drainage and the morbidity and mortality associated with pancreaticoduodenectomy. Recent reports have suggested that preoperative biliary drainage increases the perioperative morbidity and mortality rates of pancreaticoduodenectomy. Peri-operative morbidity and mortality were evaluated in 300 consecutive patients who underwent pancreaticoduodenectomy. Univariate and multivariate logistic regression analyses were done to evaluate the relationship between preoperative biliary decompression and the following end points: any complication, any major complication, infectious complications, intraabdominal abscess, pancreaticojejunal anastomotic leak, wound infection, and postoperative death. Preoperative prosthetic biliary drainage was performed in 172 patients (57%) (stent group), 35 patients (12%) underwent surgical biliary bypass performed during prereferral laparotomy, and the remaining 93 patients (31%) (no-stent group) did not undergo any form of preoperative biliary decompression. The overall surgical death rate was 1% (four patients); the number of deaths was too small for multivariate analysis. By multivariate logistic regression, no differences were found between the stent and no-stent groups in the incidence of all complications, major complications, infectious complications, intraabdominal abscess, or pancreaticojejunal anastomotic leak. Wound infections were more common in the stent group than the no-stent group. Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.

RBC transfusion and postoperative length of stay in the hospital or the intensive care unit among patients undergoing coronary artery bypass graft surgery: the effects of confounding factors.

Data on the independent association between perioperative allogeneic blood transfusion (ABT) and postoperative length of stay at the hospital or in the intensive care unit (ICU) are sparse. The records of 421 consecutive patients undergoing coronary artery bypass graft (CABG) operations at the Massachusetts General Hospital were reviewed. The effect of perioperative ABT in explaining the variation in the postoperative length of stay (LOS) at the hospital or in the ICU was calculated after adjustment for the effects of 20 confounding factors that pertained to severity of illness, difficulty of operation, and risk of postoperative wound infection or pneumonia. Postoperative LOS averaged (mean +/- SE) 8.0 +/- 0.3 days in the hospital and 50.0 +/- 4.1 hours in the ICU. After adjustment for the effects of confounding factors, the postoperative length of hospitalization increased by 0.837 percent (95% CI, 0.249-1.425%) per RBC unit transfused (p<0.001), and the postoperative length of stay in the ICU increased by 0.873 percent (95% CI, -0.068-1.814%) per RBC unit transfused (p<0.10). Allogeneic blood transfusion was independently associated with longer postoperative stays in the hospital or the ICU, but the observed independent association is perhaps too small to be clinically relevant. This independent association may be due to a relationship between ABT and a higher incidence of septic complications of surgery, or it may reflect the function of blood transfusion as a surrogate marker for severity of illness.

Closed or Open: Wound Care After Laser Skin Resurfacing

Debate continues as to the best way to treat a patient after laser skin resurfacing. Although it has become clear in the last few years that closed dressings decrease postoperative discomfort, a major concern is that such dressings increase the risk for postoperative wound infection. In this study, the authors prospectively evaluated results in 75 patients who underwent CO2 …

Transfusion of white-cell containing allogeneic blood components and postoperative wound infection: effect of confounding factors.

Randomized controlled trials (RCTs) of the relationship between allogeneic transfusion and post-operative bacterial infection at any site have generated discordant results, but have suggested an association of transfusion with wound infection. To examine the specific association of perioperative transfusion with wound infection, we reviewed the records of 964 consecutive patients undergoing elective colorectal cancer resection at our hospital. Diagnoses of wound infection were made retrospectively by the Centers for Disease Control criteria, and transfusion was defined as number of units of white-cell containing allogeneic blood components received. The probability of wound infection in association with the transfusion was calculated following adjustment for the effects of 12 confounders that had not been previously considered in combination. These factors related to severity of illness, difficulty of operation and risk of wound infection. Wound infection developed in 39 (11.4%) transfused patients, as compared to 24 (3.9%) untransfused subjects (P < 0.0001). In the multivariate analysis, there was a trend suggesting an adverse transfusion effect, which amounted to a 7% increase in the risk of wound infection per unit of red cells or platelets transfused (relative risk [RR] = 1.07; 95% confidence interval for RR = 0.98-1.16; P = 0.1241). This marginally significant effect was related to post-operative (P = 0.1274), rather than perioperative (P = 0.3061), transfusion. We conclude that allogeneic transfusion may perhaps be associated with a small increase in the risk of post-operative wound infection, but this small effect can be established only by RCTs enrolling several thousand patients. The modest magnitude of the effect may have been responsible for the disagreements among the published RCTs.

Wound Infection in Head and Neck Surgery: Implications for Perioperative Antibiotic Treatment

Perioperative antibiotic treatment significantly reduces the risk of postoperative wound infection and is cost-effective in clean-contaminated head and neck operations. A clear consensus on the most suitable single agent or combination is, however, lacking. Most surgical wound infections involve both gram-positive and gram-negative aerobes and anaerobes; some organisms may exhibit antibiotic resistance through beta-lactamase production. Comparative trials have indicated that combinations with both aerobic and anaerobic activity provide protection superior to that achieved with single agents active against only aerobic pathogens. Recent results suggest that the beta-lactam/beta-lactamase-inhibitor combination ampicillin/sulbactam is cost-effective for perioperative treatment of patients undergoing head and neck surgery.

Efficacy of Clean v Sterile Surgical Prep Kits

The goal of preoperative skin preparation is to reduce the risk of postoperative wound infections. This study was designed to determine if a difference exists in the residual microbial flora on the skin of surgical patients who are prepped with clean versus sterile prep kits. The researchers randomly assigned 60 ambulatory surgery patients to two preoperative skin preparation groups (i.e., clean prep kits, sterile prep kits) and obtained cultures of the patients' surgical sites at three different times (i.e., before performing standard povidone-iodine scrub-and-paint skin preps, 10 minutes after the completion of the skin preps, immediately after skin closure). They used repeated mixed factorial analyses of variance to compute the differences in residual microbial counts at the patients' surgical sites. There was no difference in the residual microbial skin flora in the patients prepped with clean or sterile skin prep kits. The study results have significant cost-saving implications for health care facilities and surgical patients.

Risk factors for wound infection following celiotomy in horses

Objective To determine the prevalence of wound infection following celiotomy in horses and to determine risk factors associated with the development of such infections. Design Prospective study. Animals 210 horses that had 235 celiotomies. Procedure All horses that had celiotomies between March 1990 and March 1992 were considered for this study. Only horses that survived ≥ 10 days after surgery were included in analysis of risk factors for postoperative wound infection. Results Of the 210 horses, 161 (76.7%) were discharged; of the horses discharged, 147 horses had a single celiotomy and 14 had multiple celiotomies. Twenty-six (12.4%) horses were euthanatized during surgery and were, therefore, excluded from further analysis. Twenty-three horses died during the postoperative period. Of these 23 horses, 15 that died within 10 days of surgery also were excluded from further analysis. Thus, 169 horses were included in the analysis of risk factors for developing incisional infection. Evidence of incisional infection was observed in 43 of 169 (25.4%) horses. Increased concentration of fibrinogen in peritoneal fluid obtained prior to surgery, performing an enterotomy, and use of polyglactin 910 to close the linea alba were all significantly (P ≤ 0.05) associated with increased risk of postoperative wound infection. Whether incisional herniation developed was recorded for 76 horses. The proportion of horses with hernias among those with postoperative wound infection was 19.1 %, compared with 3.6 % of horses without evidence of postoperative wound infection, indicating a significant association between postoperative wound infection and development of incisional hernias. Clinical Implications Increased concentration of fibrinogen in peritoneal fluid prior to surgery, performing an enterotomy, and use of polyglactin 910 to close the linea alba is significantly associated with increased risk for wound infection following celiotomy in horses. (J Am Vet Med Assoc 1997;210:78–81)

Postoperative wound infection rates in dermatologic surgery.

Multiple factors related to the nature of the surgical procedure can influence the risk of wound infection in dermatologic surgery. Despite that, wound infection rates in dermatologic surgical procedures are believed to be low. This study was conducted: 1) to determine wound infection rates in Mohs and excisional surgery; and 2) to investigate if factors such as lesion type, anatomic location, postoperative defect size, number of Mohs stages required to achieve a tumor-free plane, and the type of reconstructive procedure influence the rate of surgical wound infections. Wound infection rate for 530 Mohs procedures and 517 excisions combined was 2.29%, falling within the predicted range for "clean" surgical procedures. In addition, Mohs procedures performed on the ear as well as large postoperative defects were found to have a higher rate of wound infections. Dermatologic surgery can be safely performed in an outpatient setting without a significant risk of infection. Certain anatomic sites, such as the ear, as well as size of postoperative defect, are important factors in predicting the risk of postoperative wound infection.

Postoperative Infections in Dermatologic Surgery

Although there are many factors that may increase the risk of postoperative wound infections after dermatologic surgery, the rate of infections is thought to be low. To determine the infection rate after Mohs micrographic surgery (MMS), these investigators retrospectively studied records of 1047 patients who underwent MMS with reconstruction (530 patients) or excision …

Antibiotic Prophylaxis in Clean-Contaminated Head and Neck Oncologic Surgery

The use of antibiotic prophylaxis in head and neck oncologic surgery has greatly reduced the risk of postoperative wound infection and the corresponding increase in morbidity and health care costs. Conversely, inappropriate perioperative use of antibiotics increases costs and risk to patients. Antibiotic prophylaxis is beneficial only in clean-contaminated head and neck surgery; targets are the bacterial flora that commonly inhabit the skin and upper aerodigestive tract, with antibiotics effective against gram-positive aerobic organisms and anaerobic organisms providing the best coverage. Maximum efficacy is achieved with immediate preoperative and short-term (less than 48 hours) postoperative antimicrobial administration in adequate doses. Optimum benefit from prophylaxis in head and neck oncologic surgery depends on appropriate selection and administration of antibiotics in combination with sound, established surgical principles.

Wound Infection Rates After Invasive Procedures in HIV-1 Seropositive Versus HIV-1 Seronegative Hemophiliacs

One-hundred and two patients with hemophilia A, hemophilia B, or acquired antibody to factor VIII who had undergone invasive procedures were cross referenced with patients participating in an ongoing prospective natural history study of HIV-1 infection in hemophiliacs. Matching revealed that HIV-1 status was known for 83 patients (83%) who had undergone 169 procedures between July 1979 and April 1988. Invasive procedures were classified as clean in 108 patients (63.9%), clean-contaminated in 45 (26.6%), contaminated in 2 (1.2%), and infected in 14 (8.3%). Wound infection rates by HIV-1 status were as follows (95% confidence intervals): HIV+ 1.4% (0% to 5%), HIV- 0% (0% to 9%), and procedure before testing HIV+ 1.5% (0% to 6%). There were no significant differences between the wound infection rates of HIV-positive and HIV-negative hemophiliacs nor in the wound infection rate among all three subgroups of patients (p greater than 0.5, Fisher's Exact Test). We conclude that surgery in HIV-1-infected patients who have not progressed to AIDS does not entail an increased risk of postoperative wound infections.

Postoperative wound infection: Relation to different types of operation and wound contamination categories in orthopaedic surgery

During one year, 1,407 operations were performed on inpatients in an orthopaedic department. The presence or absence of postoperative wound infection was recorded during the hospital stay, at discharge and at follow up. Wound infections were linked to operations of different contamination categories and to the different types of operation performed. Better information about the risk for postoperative wound infection and the need for antibiotic prophylaxis was provided by considering the different operation types.

Prophylactic parenteral antibiotics in clean neurosurgical procedures: a review.

Clean surgical procedures carry a risk of postoperative wound infection that is less than 5% in most hospitals. The use of prophylactic antibiotic agents in clean neurosurgical cases is controversial, and the neurosurgical literature through 1980 contains no controlled clinical trials to study its effectiveness in such cases. A report of 1732 consecutive procedures without a single postoperative wound infection in patients receiving systemic gentamicin, vancomycin, and streptomycin irrigation fluids is often quoted by neurosurgeons; however, these results have not yet been duplicated by others. Since 1980, there have been several controlled trials that support the use in clean neurosurgical cases of prophylactic antibiotics, including the vancomycin/gentamicin/streptomycin regimen and the first-generation cephalosporins. A report in 1986 of 1602 cases without a primary wound infection supports the use of a single perioperative dose of cefazolin. A review of causative organisms in postoperative wound infections demonstrates the preponderance of Gram-positive pathogens. Therefore, when antibiotic prophylaxis is indicated, adequate Gram-positive bacterial coverage, including protection against Staphylococcus infection, is required. With consideration of the present data, the cost of antibiotic therapy, and the danger of drug toxicity, a short perioperative regimen of cefazolin as prophylaxis is preferred in clean neurosurgical cases.