Surgical site infection

Short description: Infection that occurs at the site of a surgical procedure

A surgical site infection (SSI) develop when bacteria infiltrate the body through surgical incisions.[1] These bacteria may come from the patient's own skin, the surgical instruments, or the environment in which the procedure is performed.[2]

An infection is designated as an SSI if it develops at the site of a surgical wound, either because of contamination during surgery or as a result of postoperative complications. For the infection to be classified as an SSI, it should occur within 30 days after surgery or within 90 days if an implant is involved.[3]

Surgical site infections that are limited to the skin and subcutaneous tissues are classified as superficial incisional SSIs. These infections are the most common type, accounting for more than 50% of all reported surgical site infections.[3]

## Contents

* 1 Symptoms
* 2 Types
* 3 Pathogen involving
* 4 Mortality
* 5 Studies
* 5.1 Global Surgical-Site Infection score
* 6 See also
* 7 References
* 8 Further reading

## Symptoms

The symptoms of a surgical site infection (SSI) can vary depending on the severity and type of infection. Common signs include redness and pain around the area of the surgical wound. A cloudy or purulent fluid may drain from the wound, indicating infection. Fever is another common symptom, which may accompany other signs such as increased warmth, swelling, or delayed healing at the surgical site. Additional symptoms may also occur, depending on the nature and extent of the infection.[4]

## Types

SSIs occur in different areas such as skin, tissue, organs, "implanted material, like a hip replacement".[4]

The Centers for Disease Control and Prevention (CDC) classifies SSIs into three categories: superficial incisional, deep incisional, and organ/space infections.

* Superficial incisional infection: involve only the outer layer of skin where the incision was made.
* Deep incisional infection: affect deeper tissues beneath the incision, such as muscles and the surrounding connective tissues.
* Organ or space infection: occur in internal areas of the body, such as an organ or a cavity between organs, that were involved in the surgical procedure.[5]

## Pathogen involving

The microorganisms responsible for surgical site infections (SSIs) are often derived from endogenous flora. The specific pathogens involved typically vary depending on the type of surgical procedure performed. Among the most frequently identified organisms are staphylococcus aureus, coagulase-negative staphylococci, enterococcus faecalis, and escherichia coli. These pathogens reflect the microbiological environment of the surgical field and the body sites exposed during the operation.[6]

## Mortality

SSIs are a significant cause of complications following surgery, contributing to both perioperative morbidity and mortality. These infections are responsible for a large number of healthcare-associated infections globally, including over 2 million cases annually in the United States alone.[3]

## Studies

There has been ongoing research on the SSIs, with the National Institute for Health and Care Research (NIHR) Global Research Health Unit on Global Surgery and GlobalSurg Collaborative. Several keypoints have been identified as Low income countries have a disproportionately greater burden of SSIs (with 4 times the burden in children) than other countries and higher rates of antibiotic resistance.[7][8] More studies have investigated the role of perioperative high fraction Oxygen and Telemedicine in preventing and improving outcomes of SSIs.[9][10]

A study conducted by researchers at the University of Washington School of Medicine, published in 2024 and featured by the University of Minnesota[11] and the American Association for the Advancement of Science,[12] and Nature[13] involved 210 adult patients undergoing spinal fusion surgery and found that most infections following surgery were caused by bacteria already present on the patients' skin.[14][15]

The researchers aimed to understand why surgical site infections (SSIs), which occur in about 1 in 30 surgeries, have not decreased despite infection prevention measures. They analyzed preoperative patient microbiomes and postoperative SSI samples using genomic analysis.[14] Of the 210 patients, 14 (6.8%) developed SSIs. Skin, nasal, and rectal samples were taken before surgery from most patients. Whole genome sequencing of 22 SSI samples revealed that 86% were similar to bacterial strains found on the patients' skin before surgery. Further analysis of 59 additional SSIs in the same hospital showed no common bacterial strains, suggesting that the infections were not linked to external hospital sources.[14]

A recent study of 150 adults undergoing ortho-spine procedures were randomized subjects pre-operatively to self-cleanse at home with 2% chlorhexidine gluconate and aloe-vera infused wipes or soap and water the night prior to surgery. Skin cultures were collected pre-cleansing, day of surgery at admission pre-operative, at hospital discharge and at the post-operative follow up visit with the surgeon (4–6 weeks post operative). The study revealed those cleansing with chlorhexidine gluconate (CHG) had statistically significantly less bacterial skin burden (including pathogens commonly associated with development of surgical site infections) than those who used soap and water. This protection lasted up to 4 days, perhaps due to the inclusion of aloe vera in the wipes moistening the skin allowing the CHG to cross several epidermal layers. This is important as the first 3–4 days after incision is the most vulnerable time as the skin epithelizes and heals forming a barrier to pathogens.[16]

A 2025 study of adults undergoing surgery for extremity or pelvic fractures reported that iodine povacrylex in isopropyl alcohol, when used for preoperative skin antisepsis in closed fracture surgery, was associated with fewer surgical site infections within 90 days than chlorhexidine gluconate in isopropyl alcohol. Infection rates after open fractures and the likelihood of unplanned fracture-related reoperation within one year were similar between the two antiseptic solutions.[17]

### Global Surgical-Site Infection score

A 'Global Surgical-Site Infection' score was published by NIHR Global Research Health Unit on Global Surgery and GlobalSurg Collaborative that allows the SSIs risk prediction with perioperative variables.[18]

## See also

* Wound dehiscence
* Prosthetic joint infection

## References

1. ↑ Ly, Chen (10 Apr 2024). "Post-surgery infections may mainly be caused by skin bacteria". https://www.newscientist.com/article/2426356-post-surgery-infections-may-mainly-be-caused-by-skin-bacteria/.
2. ↑ "Surgical site infection". 1 Jan 1900. https://www.who.int/teams/integrated-health-services/infection-prevention-control/surgical-site-infection.
3. ↑ 3.0 3.1 3.2 Zabaglo, Mate; Leslie, Stephen W.; Sharman, Tariq (5 Mar 2024). "Postoperative Wound Infections". StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560533/.
4. ↑ 4.0 4.1 "Surgical Site Infection Basics". 28 Jun 2024. https://www.cdc.gov/surgical-site-infections/about/index.html.
5. ↑ "Surgical Site Infections". https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=134&contentid=144.
6. ↑ Owens, C.D.; Stoessel, K. (2008). "Surgical site infections: epidemiology, microbiology and prevention". Journal of Hospital Infection (Elsevier BV) 70: 3–10. doi:10.1016/s0195-6701(08)60017-1. ISSN 0195-6701.
7. ↑ Bhangu, Aneel; Ademuyiwa, Adesoji O.; Aguilera, Maria Lorena; Alexander, Philip; Al-Saqqa, Sara W.; Borda-Luque, Giuliano; Costas-Chavarri, Ainhoa; Drake, Thomas M. et al. (2018-05-01). "Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study" (in English). The Lancet Infectious Diseases 18 (5): 516–525. doi:10.1016/S1473-3099(18)30101-4. ISSN 1473-3099. PMID 29452941.
8. ↑ Drake, Thomas M.; Pata, Francesco; Ghosh, Dhruv; Ademuyiwa, Adesoji O.; Arnaud, Alexis; Bhangu, Aneel; Fitzgerald, J. Edward; Glasbey, James et al. (2020-12-03). "Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study" (in en). BMJ Global Health 5 (12). doi:10.1136/bmjgh-2020-003429. ISSN 2059-7908. PMID 33272940. PMC 7716674. https://gh.bmj.com/content/5/12/e003429.
9. ↑ Surgery, NIHR Global Health Research Unit on Global; Collaborative, GlobalSurg (2023). "Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis" (in en-US). Annals of Surgery 277 (6): e1331. doi:10.1097/SLA.0000000000005506. ISSN 0003-4932.
10. ↑ Biccard, Bruce M.; Smith, Denton; Peters, Shrikant; Boutall, Adam; Wilson, Graeme; Coetzee, Ettienne; Flint, Margot; Gumede, Simphiwe et al. (2023-09-01). "Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries". BJA Open 7. doi:10.1016/j.bjao.2023.100207. ISSN 2772-6096.
11. ↑ "Many surgical site infections begin with the microbiome". 11 Apr 2024. https://newsroom.uw.edu/news-releases/many-surgical-site-infections-begin-with-the-microbiome.
12. ↑ Long, Dustin R.; Bryson-Cahn, Chloe; Waalkes, Adam; Holmes, Elizabeth A.; Penewit, Kelsi; Tavolaro, Celeste; Bellabarba, Carlo; Zhang, Fangyi et al. (10 Apr 2024). "Contribution of the patient microbiome to surgical site infection and antibiotic prophylaxis failure in spine surgery". Science Translational Medicine 16 (742). doi:10.1126/scitranslmed.adk8222. ISSN 1946-6234. PMID 38598612.
13. ↑ Hope, Derick; Ampaire, Lucas; Oyet, Caesar; Muwanguzi, Enoch; Twizerimana, Hillary; Apecu, Richard Onyuthi (21 Nov 2019). "Antimicrobial resistance in pathogenic aerobic bacteria causing surgical site infections in Mbarara regional referral hospital, Southwestern Uganda". Scientific Reports (Springer Science and Business Media LLC) 9 (1): 17299. doi:10.1038/s41598-019-53712-2. ISSN 2045-2322. PMID 31754237. Bibcode: 2019NatSR...917299H.
14. ↑ 14.0 14.1 14.2 Dall, Chris (11 Apr 2024). "Study: Pathogens that cause surgical infections may be coming from patients' skin". https://www.cidrap.umn.edu/antimicrobial-stewardship/study-pathogens-cause-surgical-infections-may-be-coming-patients-skin.
15. ↑ "Study: Pathogens that cause surgical infections may be coming from patients' skin". 12 Apr 2024. https://www.healthleadersmedia.com/clinical-care/study-pathogens-cause-surgical-infections-may-be-coming-patients-skin.
16. ↑ Card, Elizabeth (2024). "A Randomized Controlled Trial of 2% Chlorhexidine Gluconate Skin Preparation Cloths for the Prevention of Surgical Site Infections in Adults Undergoing Spine Surgeries: Residual Reduction in Skin Bacterial Load for 4 Days". HCA Healthcare Journal of Medicine 5 (5): 539–549. doi:10.36518/2689-0216.1997. PMID 39524950. PMC 11547275. https://scholarlycommons.hcahealthcare.com/hcahealthcarejournal/vol5/iss5/9/.
17. ↑ "Comparing Two Antiseptic Skin Solutions for Patients Receiving Surgery for Fractures: Clinician Evidence Update" (in en). Patient-Centered Outcomes Research Institute (PCORI). 2025-09-19. https://www.pcori.org/evidence-updates/comparing-two-antiseptic-skin-solutions-patients-receiving-surgery-fractures.
18. ↑ NIHR Global Research Health Unit on Global Surgery and GlobalSurg Collaborative (2024-06-01). "Development and external validation of the 'Global Surgical-Site Infection' (GloSSI) predictive model in adult patients undergoing gastrointestinal surgery". British Journal of Surgery 111 (6). doi:10.1093/bjs/znae129. ISSN 1365-2168. PMC 11192061. https://academic.oup.com/bjs/article/111/6/znae129/7696992.

## Further reading

* Sawyer, Robert G.; Evans, Heather L.; Hedrick, Traci L. (1 Oct 2019). "Technological Advances in Clinical Definition and Surveillance Methodology for Surgical Site Infection Incorporating Surgical Site Imaging and Patient-Generated Health Data". Surgical Infections (Mary Ann Liebert Inc) 20 (7): 541–545. doi:10.1089/sur.2019.153. ISSN 1096-2964. PMID 31460834.
* Bhattacharya, Susmita (2016). "Surgical Site Infection by Methicillin Resistant Staphylococcus aureus– on Decline?". Journal of Clinical and Diagnostic Research (JCDR Research and Publications) 10 (9): DC32–DC36. doi:10.7860/jcdr/2016/21664.8587. ISSN 2249-782X. PMID 27790436.

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