Control measures to prevent surgical site infection following gastrointestinal procedures in adults
- Deverick J Anderson, MD, MPH
Deverick J Anderson, MD, MPH
- Associate Professor of Medicine
- Duke University Medical Center
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
The rate of surgical site infections (SSIs) is low for most surgical procedures. Because of the relatively large surgical volume in many community hospitals, SSIs are the most common healthcare-associated infection . The United States Centers for Disease Control and Prevention has developed criteria that define SSI as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted at surgery . SSIs are often localized to the incision site but can also extend into deeper adjacent structures.
Gastrointestinal procedures are among the highest risk procedures for SSI due to the presence of intraluminal bacteria. According to data published by the National Healthcare Safety Network, rates of SSI following bile duct, liver, or pancreatic surgery are as high as 10 per 100 procedures. Rates of SSI following colon surgery are approximately 5 per 100 procedures, and rates of SSI following gallbladder surgery are 0.7 per 100 procedures .
Issues related to prevention of SSI following gastrointestinal procedures will be reviewed here. Issues related to epidemiology of SSI and general principles of SSI prevention are discussed further separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Overview of control measures for prevention of surgical site infection in adults".)
There are two key components of antimicrobial prophylaxis for prevention of surgical site infection (SSI) following gastrointestinal procedures: antibiotic selection and timing of administration (to optimize tissue concentration at the time of surgery). The choice of agents depends on the type of procedure, as discussed in the following sections (table 1). Timing of administration is discussed separately. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Timing'.)
Gastroduodenal procedures — Antimicrobial prophylaxis with cefazolin is warranted for patients undergoing clean-contaminated procedures during which the lumen of the intestinal tract is entered [4,5]. These include ulcer resection, carcinoma resection, perforation repair, gastric outlet stricture repair, percutaneous endoscopic gastrostomy (PEG) insertion, pancreaticoduodenectomy (Whipple procedure), and bariatric surgical procedures. (See "Partial gastrectomy and gastrointestinal reconstruction" and "Total gastrectomy and gastrointestinal reconstruction" and "Gastrostomy tubes: Placement and routine care".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lewis SS, Moehring RW, Chen LF, et al. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol 2013; 34:1229.
- April 2013 CDC/NHSN Protocol Corrections, Clarification, and Additions http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf (Accessed on July 10, 2013).
- Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control 2009; 37:783.
- Jafri NS, Mahid SS, Minor KS, et al. Meta-analysis: antibiotic prophylaxis to prevent peristomal infection following percutaneous endoscopic gastrostomy. Aliment Pharmacol Ther 2007; 25:647.
- Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol 2000; 95:3133.
- Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett 2009; 7:47.
- Lewis RT, Goodall RG, Marien B, et al. Efficacy and distribution of single-dose preoperative antibiotic prophylaxis in high-risk gastroduodenal surgery. Can J Surg 1991; 34:117.
- Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
- Sjöstedt S, Levin P, Malmborg AS, et al. Septic complications in relation to factors influencing the gastric microflora in patients undergoing gastric surgery. J Hosp Infect 1989; 13:191.
- Petrosillo N, Drapeau CM, Nicastri E, et al. Surgical site infections in Italian Hospitals: a prospective multicenter study. BMC Infect Dis 2008; 8:34.
- Watanabe A, Kohnoe S, Shimabukuro R, et al. Risk factors associated with surgical site infection in upper and lower gastrointestinal surgery. Surg Today 2008; 38:404.
- Yeo CJ, Cameron JL, Sohn TA, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 1999; 229:613.
- Chang WT, Lee KT, Chuang SC, et al. The impact of prophylactic antibiotics on postoperative infection complication in elective laparoscopic cholecystectomy: a prospective randomized study. Am J Surg 2006; 191:721.
- Koc M, Zulfikaroglu B, Kece C, Ozalp N. A prospective randomized study of prophylactic antibiotics in elective laparoscopic cholecystectomy. Surg Endosc 2003; 17:1716.
- Varela JE, Wilson SE, Nguyen NT. Laparoscopic surgery significantly reduces surgical-site infections compared with open surgery. Surg Endosc 2010; 24:270.
- Siddiqui K, Khan AF. Comparison of frequency of wound infection: open vs laparoscopic cholecystectomy. J Ayub Med Coll Abbottabad 2006; 18:21.
- Harris A, Chan AC, Torres-Viera C, et al. Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999; 31:718.
- van den Hazel SJ, Speelman P, Dankert J, et al. Piperacillin to prevent cholangitis after endoscopic retrograde cholangiopancreatography. A randomized, controlled trial. Ann Intern Med 1996; 125:442.
- Mallery JS, Baron TH, Dominitz JA, et al. Complications of ERCP. Gastrointest Endosc 2003; 57:633.
- Baquero F, Hsueh PR, Paterson DL, et al. In vitro susceptibilities of aerobic and facultatively anaerobic gram-negative bacilli isolated from patients with intra-abdominal infections worldwide: 2005 results from Study for Monitoring Antimicrobial Resistance Trends (SMART). Surg Infect (Larchmt) 2009; 10:99.
- Jethwa P, Breuning E, Bhati C, et al. The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery. Aliment Pharmacol Ther 2007; 25:1175.
- Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322.
- Andersen BR, Kallehave FL, Andersen HK. Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev 2005; :CD001439.
- Sauerland S, Lefering R, Neugebauer EA. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2004; :CD001546.
- Schnüriger B, Inaba K, Eberle BM, et al. Microbiological profile and antimicrobial susceptibility in surgical site infections following hollow viscus injury. J Gastrointest Surg 2010; 14:1304.
- den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev 2008; :CD006438.
- Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012; :CD003769.
- Yin Y, Song T, Liao B, et al. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg 2012; 78:359.
- Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment. Surg Infect (Larchmt) 2011; 12:205.
- Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2009; :CD001181.
- Baum ML, Anish DS, Chalmers TC, et al. A survey of clinical trials of antibiotic prophylaxis in colon surgery: evidence against further use of no-treatment controls. N Engl J Med 1981; 305:795.
- Coppa GF, Eng K. Factors involved in antibiotic selection in elective colon and rectal surgery. Surgery 1988; 104:853.
- Glenny AM, Song F. Antimicrobial prophylaxis in colorectal surgery. Qual Health Care 1999; 8:132.
- Nichols RL. Prophylaxis for intraabdominal surgery. Rev Infect Dis 1984; 6 Suppl 1:S276.
- Condon RE, Bartlett JG, Nichols RL, et al. Preoperative prophylactic cephalothin fails to control septic complications of colorectal operations: results of controlled clinical trial. A Veterans Administration cooperative study. Am J Surg 1979; 137:68.
- Skipper D, Karran SJ. A randomized prospective study to compare cefotetan with cefuroxime plus metronidazole as prophylaxis in elective colorectal surgery. J Hosp Infect 1992; 21:73.
- Song F, Glenny AM. Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomised controlled trials. Health Technol Assess 1998; 2:1.
- Itani KM, Wilson SE, Awad SS, et al. Ertapenem versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med 2006; 355:2640.