Recognition, Prevention, Surveillance, and Management of Surgical Site Infections: Introduction to the Problem and Symposium Overview

Surgical site infections (SSIs) are the second most common types of nosocomial infection in the United States. Approximately 500,000 SSIs occur annually, accounting for 3.7 million excess hospital days and >$1.6 billion in extra hospital charges [1]. Gram-positive organisms, many of which are resistant to multiple antimicrobial agents, are isolated from 46% of patients with SSIs. The problem of antimicrobial resistance in gram-positive nosocomial pathogens has been of growing concern and will continue to pose great clinical and epidemiological challenges in the foreseeable future. Surveillance of surgical site infections has been shown to be a powerful preventative tool when the data are acquired, analyzed, and used appropriately. As Gaynes et al. [2] point out, feedback of SSI data to practicing surgeons has been shown in multiple studies to be associated with improved SSI infection rates [2]. Recently, progress has been made in refining SSI surveillance data to provide risk-adjusted rates, which might be used to compare surgical outcomes among surgeons or among facilities. Newer statistical techniques include logistic regression models of individual procedures and standardized infection ratios. However, the surveillance of SSIs has been complicated by recent changes in surgical practice, such as shortened duration of postoperative stay, outpatient procedures, and laparoscopic procedures. These and other surveillance issues are the subject of ongoing study in the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance system. Some of these issues have been carefully addressed [2]. Inappropriate surgical prophylaxis continues to be a major problem nationally. Inappropriate use of antimicrobial agents not only adds to the cost of medical care, but also needlessly exposes the patient to potential toxicity and risks that promote the development and spread of antimicrobial resistance in health care facilities. According to Burke [3], appropriate surgical prophylaxis is a multifactorial enterprise that depends on proper case selection, antibiotic selection, dosing and route of administration, duration of therapy, and, for lengthy procedures, intraoperative dosing. Significant cost savings and improved infection rates have been shown to accrue with use of surgical antimicrobial prophylaxis. Burke stresses the critical importance of proper timing of antimicrobial prophylaxis and offers suggestions regarding how to optimize this and the many other important parameters attendant with surgical antimicrobial prophylaxis in the health care setting. Nichols and Florman [4] review the clinical presentation of many types of skin and soft-tissue infections, some of which are commonplace, such as impetigo, and others of which are medical and surgical emergencies, such as Fournier's gangrene. The need for immediate surgical intervention is emphasized when a condition in the gangrene complex is suspected; graphic images are provided to highlight their importance and potential destructiveness. The authors give their perspective on how to treat skin and soft-tissue infections caused by unusually resistant organisms and provide a framework for using some of the newly available therapeutic agents that are active against gram-positive organisms [4]. Taking off from this theme of resistant gram-positive skin and soft-tissue infections, Widmer [5] tackles the nettlesome problem of diagnosing and treating infections in patients with orthopedic implants. He presents an interesting analytic perspective on the diagnostic tools available to help recognize infections in orthopedic implants and offers an encouraging nonsurgical alternative to managing a subset of these infections [5]. Surgical site infections will continue to be important causes of morbidity and mortality in the hospital and outpatient setting. Recognition, prevention, surveillance, and management of surgical site infections are interrelated issues that will continue to demand the attention of clinicians and epidemiologists alike. In this symposium, authors brought their individual perspectives to bear on specialized aspects of these 4 important issues.