'O' Choosing the appropriate prophylactic antimicrobial relies on anticipating which organisms will be encountered during the operation. SSIs associated with extra-ab dominal operations are the result of skin flora organisms in nearly all cases. These organisms include gram-positive cocci, with S. aureus and Staphylococcus epiderm-idis being among the most frequently isolated SSI pathogens according to the National Nosocomial Infections Surveillance System (NNIS)5 (Table 85-2). Streptococcus spp. and other gram-positive aerobes may also be implicated.

Table 85-1 National Red Cross Wound Classification, Risk of SSI, and Antibiotic Indication

Classification Description

SSI Antibiotic Risk Prophylaxis





No acute inflam- Low mation or transection of Gl, oropharyngeal. GU, biliary, or respiratory tracts; elective case, no technique break

Controlled opening of aforementioned tracts with minimal spillage or minor technique break; clean procedures performed emergently or with major technique breaks

Acutc, nonpurulent High inflammation present; major spillage or technique break during clean-contaminated procedures

Obvious pre-existing — infection present (abscess, pus, or necrotic tissue


Medium Indicated


Not indicated; antibiotics used for treatment

Intra-abdominal operations involve a diverse flora with the potential for polymi-crobial SSIs. Escherichia coli make up a large portion of bowel flora and are frequently isolated as pathogensaccording to the NNIS.5 Other entericgram-negative bacteria, as well as anaerobes (especially Bacteroides spp.), may be encountered during intra-abdominal operations.

Candida albicans is being implicated as the cause of a growing number of SSIs. According to the NNIS, from 1991 to 1995, the incidence of fungal SSIs rose from 0.1 to 0.3 per 1,000 discharges.5 Increased use of broad-spectrum antimicrobials and rising prevalence ofimmunocompromised and human immunodeficiency virus-infected individuals are factors in fungal SSIs. Despite this increase, antifungal prophylaxis for surgery is not currently recommended.

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