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): 908-914 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 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
Lim TJ Table 1. Distribution of pathogens isolated* from surgical site infections, national nosocomial infections surveillance system, (1986~1996) Percentage of Isolates Pathogen 1986~1989 1990~1996 (N=16,727) (N=17,671) Staphylococcus aureus 17 20 Coagulase negative staphylococci 12 14 Enterococcus spp. 13 12 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
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
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Lim TJ Peer Reviewer Commentary 914