Keys To Managing Postoperative Wound Infections

Ryan Fitzgerald, DPM, FACFAS

In a thorough review of the literature on surgical site infections, this author shares insights on key risk factors, discusses current concepts and controversies with preventative measures, and offers a salient overview on common pathogens.

   Numerous studies have demonstrated that postoperative infections following elective, clean foot and ankle surgery are relatively uncommon. Indeed, a review of the recent literature from the Centers for Disease Control and Prevention (CDC) shows the surgical site infection (SSI) rate to be approximately 2.1 percent for these types of surgical procedures.1 However low the relative incidence may be for the development of postoperative infection following lower extremity surgery, the management of these types of complications can present a challenge to every surgeon. The presence of postoperative wound infections often delays the recovery of surgical patients and these complications commonly increase the length of stay in the inpatient setting.2,3

   Furthermore, surgical site infections may produce long-lasting sequelae that can require additional medical and surgical management as well as further nursing care. This creates both a psychological drain on the patient as well as a financial drain on an already besieged healthcare system.4 Consequently, the effective diagnosis, management and ultimate prevention of surgical site infections are relevant to providing quality patient care in an ever evolving healthcare environment.

   Various studies demonstrate that a reduction in surgical site infections is directly related to increased education (for the surgeon, the operating room team and the patient) and awareness of the causes and risk factors for the development of postoperative infections. A critical evaluation of infection control practices has furthermore shown a reduction in postoperative infection rate, particularly in those instances in which regular feedback is provided to the surgeon following surveillance for wound infection.1 It is important to note, however, that simple surveillance is not adequate to provide essential reductions in infection propagation. Action and prevention are key, and appropriate prevention of surgical site infection begins prior to the surgical encounter.

A Closer Look At Risk Factors For Surgical Site Infections

There are numerous risk factors that can predispose one to the development of surgical site infections. These risk factors have been validated and documented in the literature, and they combine to provide the relative risk for the development of postoperative infections. It is important for the surgeon to recognize the potential risk factors in his or her surgical patients, and subsequently initiate the chain of action that can attempt to prevent or at least minimize the potential for the development of surgical site infections.

   These factors can be divided into essentially two categories, intrinsic and extrinsic factors. Intrinsic factors are those factors related to the patient and to the surgical procedure being performed. Patient-related risk factors include the patient’s age, the presenting condition, the potential for concomitant disease, preexisting infection, tobacco usage, malnutrition, obesity and uncontrolled diabetes. These are all independent risk factors for developing a postoperative infection.5-7

   Sorenson and colleagues found the optimal abstinence period required in heavy smokers to reduce the risk of surgical site infections was four weeks.8 Malnutrition lowers a host’s defenses and compromises the immune system, thus predisposing the patient to infection and poor wound healing.9 Recognizing at-risk patients prior to surgery is essential to successful management of these complicated patients during the perioperative period.

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