During the second half of the 19th century many operations were developed after anesthesia

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1 Continuing Education Column Surgical Site Infection and Surveillance Tae Jin Lim, MD Department of Surgery, Keimyung University College of Medicine E mail : tjlim@dsmc.or.kr J Korean Med Assoc 2007; 50(10): Abstract During the second half of the 19th century many operations were developed after anesthesia was introduced but advances were limited for many years because of the high rate of infection and the high mortality rate that followed infections. After the introduction of the principle of antisepsis, postoperative infectious morbidity decreased substantially. With the introduction of antibiotic therapy in the middle of the 20th century, a new adjunctive method to treat and prevent surgical infections was discovered. However, not only have postoperative wound and hospital required infections continued, but widespread antibiotic therapy has often made prevention and control of surgical infections more difficult. Based on National Nosocomial Infection Surveillance (NNIS) system reports, SSIs (Surgical Site Infections) are the third most common nosocomial infection, accounting for 14% to 16% of all nosocomial infections among hospitalized patients. It is also a significant source of postoperative morbidity, resulting in increased hospital length of stay and increased cost. Determination of risk factors for the development of SSI has been a major focus of surgical research. To reduce the rate of SSIs we have to eliminate risk factors of SSIs and keep a continuous surveillance with feedback of information to surgeons and other relevant staff. A successful SSI surveillance program includes standardized definition of infection, effective surveillance method, and stratification of the SSIs rates according to risk factors. Because SSIs may be the most preventable of nosocomial infections, health care facilities should make special efforts to reduce the risk of development of these surgical complications. The evaluation of infection control programs and the development of more effective infection control strategies should be established and surgeons should be more concern about SSI control. Keywords : SSI; Risk factors; Surveillance; Nosocomial infection; CDC's NNIS system 908

Surgical Site Infection and Surveillance Skin Subcutaneous tissue (Fat) Superficial Incisional SSI Within 30 days after surgery *Superficial + Deep incisional layers are handled as the deep layer

2 Surgical Site Infection and Surveillance Skin Subcutaneous tissue (Fat) Superficial Incisional SSI Within 30 days after surgery *Superficial + Deep incisional layers are handled as the deep layer Exclusion: Suture abscess, infectious burns / episiotomy wounds Deep soft tissue (Muscle+Fascia) Deep Incisional SSI Within 30 days after surgery (Within 1 year for implants) *Deep incisional + Organ / Space are handled as Organ / Space Organ / Space Organ / Space SSI Within 30 days after surgery (Within 1 year for implants) Figure 1. Schematic of SSI anatomy and appropriate classification. 909

3 Lim TJ Table 1. Distribution of pathogens isolated* from surgical site infections, national nosocomial infections surveillance system, (1986~1996) Percentage of Isolates Pathogen 1986~ ~1996 (N=16,727) (N=17,671) Staphylococcus aureus Coagulase negative staphylococci Enterococcus spp Escherichia coli 10 8 Pseudomonas aeruginosa 8 8 Enterobacter spp. 8 7 Proteus mirabilis 4 3 Klebsiella pneumoniae 3 3 Other Streptococcus spp. 3 3 Candida albicans 2 3 Group D streptococci 2 (non enterococci) Other gram positive aerobes 2 Bacteroides fragilis 2 *: Pathogens representing less than 2% of isolates are excluded 910

4 Surgical Site Infection and Surveillance Table 2. SSI Surveillance (19) USA JAPAN UK Netherland Name NNIS National Nosocomial Infection Surveillance JNIS Japanese Nosocomial Infection Surveillance NINNS Nosocomial Infection National Surveillance Scheme PREZIES PREventie van ZIEkenhuisinfectie s door Surveillance Deelcomponent postoperatieve wondinfecties System CDC Center for Disease Control and Prevention Japanese Environmental Infection Committee JNIS PHLS Public Health Laboratory Service National Institute of Public Health and the Environment Scale More than 300 Institute (more than 100,000 cases) (2001) 9 Institute (5,176 cases) (2001) 70 Institute (13,776 cases) (1998) 57 Institute (43,313 cases) (1998) 911

5 Lim TJ 11. Mangram A. Horan TC, Silver LC, Jarvise WR. CDC guidelines for prevention of surgical site infection. Infection Control & Hospital Epidemiology 1909; 20: Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbial Rev 1993; 6: Leaper DJ, van Goor H, Rei lly J, Petrosillo N, Geiss HK, Torres AJ, Berger A. Surgical Site Infection A European Perspective of Incidence & Economic Burden. Int Wound J 2004; 1: Kathryn BK, Jane PB, Sharon LT, William EW, Daniel JS. The Impact of Surgical Site Infections in the 1990s: Attributable Mortality, Excess Length of Hospitalization, and Extra Costs. Infection Control and Hospital Epidemiology Vol. 20 No 11; Edmiston CE, Seabrook GR, Goheen MP, Krepel CJ, Johnson CP, Lewis BD, Brown KR, Towne JB. Bacterial adherence to surgical sutures: Can Antibacterial Coated Sutures Reduce the Risk of Microbial Contamination? J Am Coll Surg 2006; 203: Park ES, Kim KS, Lee WJ, Jang SY, Choi JY, Kim JM. The economical impacts of surgical site infection. Korean Journal of Nosocomial Infection Control 2005; 10: Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC Definitions of Nosocomial Surgical Site Infections, 1992: A Modification of CDC Definitions of Surgical Wound Infections. Infect Control Hosp Epidemiol 1992; 13: Nooyen SM, Overbeek BP, Brutel de la Riviere A, Storm AJ, Langemeyer JM. Prospective randomised comparison of single dose versus multiple dose cefuroxime for prophylaxis in coronary artery bypass grafting. Eur J Clin Microbiol Infect Dis 1994; 13: Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986 April 1996, issued May A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control 1996; 24: Schaberg DR. Resistant gram positive organisms. Ann Emerg 912

6 Surgical Site Infection and Surveillance Med 1994; 24: Jarvis WR. Epidemiology of nosocomial fungal infections, with emphasis on Candida species. Clin Infect Dis 1995; 20: Farrin A. Manian. Surveillance of surgical site infections in altenative settings: Exploring the current options. AJIC Vol. 25, No. 2: Condon RE, Schulte WJ, Malangoni MA, Anderson Teschendorf MJ. Effectiveness of a surgical wound surveillance program. Arch Surg 1983; 118: Center for Disease Control. Outline for surveillance and control of nosocomial infections. Center for Disease Control Atlanta, NNIS Report: National Nosocomial Infections Surveillance (NNIS) System Report, Data summary from January 1992 June 2002, Issued August American J Infect Control. 2002; 30: Central Public Health Laboratory. Surgical site infection analysis of year s surveillance in English hospitals, Geubbles EL, Mintjes de Groot AJ, vanden Berg JM, de Boer AS. An operating surveillance system of surgical site infections in the Netherlands. Infect Control Hosp Epidemiol 2002; 21: Lee SO. The 10th Training Course for Nosocomial Infection Control. Korean Society for Nosocomial Infection Control 2006; HY Kobayashi. Surgical Site Infection Surveillance. 1st ed. Medica, 2003:

7 Lim TJ Peer Reviewer Commentary 914

Chapter Anaerobic infections (individual fields): prevention and treatment of postoperative infections

Chapter Anaerobic infections (individual fields): prevention and treatment of postoperative infections J Infect Chemother (2011) 17 (Suppl 1):62 66 DOI 10.1007/s10156-010-0141-x GUIDELINES Chapter 2-5-1. Anaerobic infections (individual fields): prevention and treatment of postoperative infections Ó Japanese