Key concepts

0 Surgical site infections (SSIs) are a significant cause of morbidity and mortality.

01 The distinction between prophylaxis and treatment influences the choice of antimicrobial and duration of therapy.

Surgical operations are classified as clean, clean-contaminated, contaminated, or dirty.

Choosing the appropriate prophylactic antimicrobial relies on anticipating which organisms are likely to be encountered during the operation.

A thorough drug allergy history should be taken to discern true allergy (anaphyl-axis) from other adverse events (stomach upset).

Further study is needed before antibiotic-impregnated bone cements can be recommended as an alternative to preoperative prophylaxis with traditional antimicrobials for orthopedic operations.

For prevention of SSIs, correct timing of antimicrobial administration is imperative so as to allow the persistence of therapeutic concentrations in the blood and wound tissues during the entire course of the operation.

The goal of antimicrobial dosing for surgical prophylaxis is to optimize the phar-macodynamic parameter of the selected agent against the suspected organism for the duration of the operation.

© The duration of antimicrobial prophylaxis should not exceed 24 hours (48 hours for cardiac surgery); additional doses of antimicrobial past this time point do not demonstrate added benefits.

® According to Centers for Disease Control and Prevention criteria, SSI may appear up to 30 days after an operation and up to 1 year if a prosthesis is implanted.

O Surgical site infections (SSIs) are a significant cause of morbidity and mortality. Approximately 2% to 5% of patients undergoing clean extra-abdominal operations and 20% undergoing intra-abdominal operations will develop an SSI.1 SSIs have become the second most common cause of nosocomial infection and these data are likely underestimated.1 More than 70% of surgical procedures are now performed on an outpatient basis, creating a significant potential for under-reporting.

SSIs negatively affect patient outcomes and increase health care costs. Patients who develop SSIs are five times more likely to be readmitted to the hospital and have twice the mortality of patients who do not develop an SSI.1 A patient with an SSI

is also 60% more likely to be admitted to an ICU. SSIs increase lengths of hospital stay and costs.1,3,4 The type of SSI can also affect the severity of a patient's negative outcome due to surgery. Deep SSIs, involving organs or spaces, result in longer durations of hospital stay and higher costs compared to SSIs that are limited to the incision.5 Additionally, beginning in 2008, Medicare and Medicaid Services will no longer reimburse the hospitals for any cost incurred from treating certain hospital-acquired infections, including SSIs.6 Thus, even greater importance is placed on preventing infection, and, if infection should occur, treatment of the infection should be for the shortest duration possible and in the most cost effective manner.

SSIs are defined and reported according to Centers for Disease Control and Prevention (CDC) criteria.5 SSIs are classified as either incisional or organ/space. Incisional SSIs are further divided into superficial incisional SSI (skin or subcutaneous tissue) and deep incisional SSI (deeper soft tissues of the incision). Organ/space SSIs involve any anatomic site other than the incised areas. For example, a patient who develops meningitis after removal of a brain tumor could be classified as having an organ/space SSI. An infection is considered as SSI if any of the above criteria is met and the infection occurs within 30 days of the operation. If a prosthetic is implanted, the timeline extends out to 1 year.

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