Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1475-3
ORIGINAL ARTICLE
Epidemiology and risk factors for surgical site infections in patients requiring orthopedic surgery Ravi Kant Jain • Rajeev Shukla • Pankaj Singh Ravindra Kumar
•
Received: 14 February 2014 / Accepted: 23 April 2014 Ó Springer-Verlag France 2014
Abstract Introduction Surgical site infection (SSI) is the most common complication following surgical procedures. The aim of this study was to determine the incidence and associated risk factors of SSI in orthopedic patients admitted in a tertiary care center. Materials and methods Data were collected which focused on demographic details, lifestyle factors, diagnosis, surgical procedure, duration of surgery, prophylactic antibiotics, postoperative antibiotics and comorbidity obtained from the patients hospital records. Univariate analysis and multinomial logistic regression tests were performed to identify independent risk factors for orthopedic incisional SSIs. Results The overall rate of SSI was 2.1 %. Univariate analysis showed diabetes, smoking and duration of hospital stay to be significantly associated with patients in whom SSI developed than in uninfected control patients. Independent risk factors for SSI that were identified by multinomial logistic regression were diabetes (OR 3.953) and smoking (OR 38.319). Conclusion Diabetes and smoking were independent risk factors for SSIs. Therefore, it is recommended to tightly regulate blood glucose levels and stop smoking to reduce the SSIs.
R. K. Jain (&) R. Shukla P. Singh Department of Orthopedics, Sri Aurobindo Medical College and PG Institute, Indore 453111, Madhya Pradesh, India e-mail: [email protected] R. Kumar Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore 453111, Madhya Pradesh, India
Keywords factors
Surgical site infection Orthopedics Risk
Introduction Surgical site infections (SSIs) are ill-fated and bothersome complications after surgeries, usually leading to increased morbidity, mortality, length of hospital stay and health care costs [1, 2]. Increased morbidity and mortality are associated with SSI, ranging from wound discharge associated with superficial skin infection to life-threatening conditions such as severe sepsis [3, 4]. In orthopedic wards, SSIs represent approximately 20 % of the overall nosocomial infections [5]. Orthopedic SSIs prolong hospital stays ranging from 12 to over 20 days, approximately double rehospitalization rates, and increase health care costs by[300 % [6, 7]. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and decreased patients’ quality of life [6, 7]. Staphylococcus aureus is a commonly isolated organism in SSI, accounting for 15–20 % of SSI occurring in hospital; other organisms regularly isolated from SSIs include gram-negative bacilli, Coagulase-negative staphylococci, Enterococcus spp. and Escherichia coli [3, 4]. Methicillinresistant S. aureus (MRSA) is an increasingly important pathogen that causes more than 50 % of S. aureus hospital acquired infections in the US and Europe and presents challenges to treatment due to multiple antibiotic resistance [8]. A major 30–50 % of antimicrobials prescribed in hospital practice are for surgical prophylaxis to prevent postoperative wound infection. A reduction in the infection rate to a minimal level could have significant benefits in terms of both patient comfort and medical resources used [9].
123
Eur J Orthop Surg Traumatol
For reduction in incidence of orthopedic SSIs, there should be proper knowledge of major risk factors in that particular community and hospital. The risk factor can be patient-related i.e., increased age, diabetes mellitus, obesity, previous surgical infection, poor nutrition, etc. and surgery-related i.e., operation duration, wound classification, excessive blood loss and antibiotic prophylaxis. Therefore, aim of the present study was to identify the major risk factors associated with orthopedic SSI and to find out the frequency of microorganism associated with SSI so that early prophylactic treatment policy can be adopted.
Materials and methods This retrospectively observational study reviewed the medical records of all 8,805 patients who had orthopedic surgeries in a tertiary care hospital between January 2011 and December 2013, among which, 1,252 patients were excluded because of various reasons including the presence of an infection prior to surgery, a contaminated surgical wound or the need for further surgery within 72 h, thus leaving 7,553 patients who were finally included in the present study. SSIs were identified by orthopedic surgeons in 159 patients based on the Centers for Disease Control and Prevention’s surgical site criteria published in 1999. Three hundred age- and sex-matched patients without any SSI were randomly selected for statistical analysis.
Results Out of 7,553 orthopedic patients requiring surgery, 159 (2.1 %) patients develop SSI during the study period. Since the number of orthopedic patients without any SSI is very large, we have a chosen 300 randomly selected age- and sex-matched orthopedic patient without any SSI as a control group for further analysis. The mean age of patient with SSI and control group was 36.28 ± 19.9 and 37.38 ± 16.3 years, respectively. The male to female ratio in SSI group was almost 3.2 (121:38). In the present study, 72 (45.9 %) of the 159 clinical SSIs were culture negative. Out of 87 culture positive samples, the most common bacteria isolated was S. aureus (28.9 %) followed by Pseudomonas aeruginosa (9.4 %), Klebsiella pneumonia (5.7 %), Mycobacteria (3.8 %), Coagulasenegative staphylococcus (1.3 %), MRSA (1.3 %) and others (4.3 %). We found a significant association of SSIs with smoking, diabetes mellitus, hypertension and duration of hospital stay. We did not observe any significant association with alcohol intake, socioeconomic status and duration of surgery (Table 1). Multinomial logistic regression analysis was done to identify independent risk factors for orthopedic incisional SSIs. Diabetes mellitus and smoking had a clear association with the occurrence of infection. Other variable that independently associated with an increased risk of orthopedic SSIs was duration of hospital stay and alcohol intake (Table 2).
Data collection Data comprising patient-related and surgery-related information were collected from the medical records using a standardized data collection independently by two investigators. Patient-related information includes age, gender, weight, underlying disorders, diagnosis, history of smoking and/or alcohol abuse previous surgeries and others. Surgery-related information covers length of hospitalization, length of preoperative stay, prosthetic implant used, type of operative procedure, duration of operation, use of antibiotics, etc. Statistical analysis To check the association between SSIs and risk factors, Fisher exact test was performed for categorical variables, and student t test was performed for continuous variables. Multinomial logistic regression was used to identify independent risk factors for SSIs. A two-tailed P \ 0.05 was considered significantly in all statistical tests. All statistical analyses were performed using SPSS software version 20.0 (SPSS Inc, Chicago, IL, USA).
123
Discussion Infections in orthopedic patients are the common cause of morbidity. Infections occur even though surgeons take meticulous aseptic precautions during surgery, and patients are strictly managed before and after surgery. The incidence rate of SSI was 2.1 % in the present study. Our study is similar to study done by Li et al. [10] on 2,061 patients requiring orthopedic surgery in China. However, our study has disparity from other previous reports from developing countries including India that shows the rate of SSIs ranging from 4.2 to 22.7 % [11–15]. Staphylococcus aureus was predominant causative organism in the present study. Khan et al. [12], Maksimovic’ et al. [13], Ibtesam et al. [14] also reported S. aureus as a main culprit for SSIs. However, Li et al. [10], Phillips et al. [16] reported Coagulase-negative staphylococci as a most common microorganism causing SSIs. Diabetes mellitus can increase infection rate and impair wound healing. Poorly controlled diabetes adversely affects the ability of leukocytes to destroy invading
Eur J Orthop Surg Traumatol Table 1 Univariate analysis of different parameters in SSIs and control group
Parameter
SSI
Control
P value
OR
95 % CI -6.836 to 0.716
Age (years)
36.28 ± 19.9
39.34 ± 19.4
0.112
–
Sex (male)
121 (76.1 %)
229 (76.0 %)
0.981
1.006
0.6407–1.578
Duration of surgery (min)
85.27 ± 41.25
81.7 ± 39.8
0.373
–
-4.426 to 11.352
Duration of hospital stay (days)
23.24 ± 16.2
19.70 ± 13.4
0.013
–
0.749–6.329
Diabetes mellitus
25 (15.7 %)
23 (7.7 %)
0.012
2.247
1.230–4.106
Hypertension
18 (11.1 %)
30 (10 %)
0.7797
1.149
0.618–2.134
Smoking
57 (35.8 %)
24 (8.0 %)
\0.0001
6.426
3.789–10.900
Alcohol
57 (35.8 %)
96 (32 %)
0.405
1.188
0.7921–1.780
23 (14.5 %)
45 (15 %)
0.098
–
–
Socio-economic status Lower Upper lower
37 (23.3 %)
97 (32.3 %)
Lower middle
99 (62.3 %)
158 (52.7 %)
Upper middle
0 (0 %)
0 (0 %)
Upper
0 (0 %)
0 (0 %)
Table 2 Multinomial logistic regression analysis between SSIs and control group Parameters
B
P value
Age
-0.012
0.056
0.989
0.977–1.000
Sex (male)
-0.449
0.066
0.607
0.357–1.033
Duration of surgery
0.000
0.906
1.000
0.994–1.005
Number of days in hospital
0.022
0.004
1.023
1.007–1.039
Diabetes
1.374
0.002
3.953
1.664–9.390
Smoke
3.646
0.000
38.319
14.109–104.076
Hypertension
0.471
0.269
1.602
0.694–3.695
-2.235
0.000
0.107
0.043–0.268
Lower
-0.121
0.711
0.886
0.469–1.676
Upper lower
-0.584
0.028
0.558
0.331–0.938
Alcohol
OR
95 % CI
Some studies found that the longer surgery length was associated with a higher SSIs risk [10, 22], whereas other studies showed no relevance between them [12, 19]. Our study also shows that there is no relationship between the surgical operation time and incidence of SSIs. In conclusion, SSIs are unavoidable in different orthopedic procedures although all aseptic precautions are taken. The possible risk factors that can be characterized are presence of diabetes, smoking and duration of hospital stay, etc. Therefore, it is recommended to tightly regulate blood glucose levels and stop smoking to reduce the SSIs. Conflict of interest
None.
Socioeconomic status
bacteria and to prevent the harmful proliferation of usually benign bacteria present in the healthy body. About 2.5 times higher risk of postoperative wound infection in diabetic patients than nondiabetic was observed in the present study (Table 1). This agrees with the findings of other researchers who all reported increased predisposition of diabetes to surgical wound infection in their different centers [17, 18] Therefore, patients with diabetes mellitus require tight glucose control before surgery. Smokers have a higher incidence of infectious and noninfectious healing complications after surgery compared with nonsmokers across all surgical specialties [19, 20]. We also found that smokers develop SSIs about 6.4 times higher than nonsmokers (Table 1). The higher surgical operation duration increased the tissue exposure time, increased surgical team technical errors and decreased organism’s systemic defenses [21].
References 1. Mangram AJ, Horan TC, Pearson ML, Silver CL, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999: hospital infection control practices advisory committee. Infect Control Hosp Epidemiol 20:250–278 2. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB (2009) Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 37:387–397 3. Anderson DJ, Kaye KS (2009) Staphylococcal surgical site infections. Infect Dis Clin North Am 23:53–72 4. Owens CD, Stoessel K (2008) Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect 70:3–10 5. Saadatian-Elahi M, Teyssou R, Vanhems P (2008) Staphylococcus aureus, the major pathogen in orthopaedic and cardiac surgical site infections: a literature review. Int J Surg 6:238–245 6. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ (2002) The impact of surgical site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 23:183–189 7. Bachoura A, Guitton TG, Smith RM, Vrahas MS, Zurakowski D, Ring D (2011) Infirmity and injury complexity are risk factors for
123
Eur J Orthop Surg Traumatol
8.
9. 10.
11.
12.
13.
14.
15.
surgical-site infection after operative fracture care. Clin Orthop Relat Res 469:2621–2630 Dulon M, Haamann F, Peters C, Schablon A, Nienhaus A (2011) MRSA prevalence in European healthcare settings: a review. BMC Infect Dis 11:138 Nandi PL, Rajan SS, Mak KC, Chan SC, So YP (1999) Surgical wound infection. Hong Kong Med J 5:82–86 Li GQ, Guo FF, Ou Y, Dong GW, Zhou W (2013) Epidemiology and outcomes of surgical site infections following orthopedic surgery. Am J Infect Control 41:1268–1271 Lilani SP, Jangale N, Chowdhary A, Daver GB (2005) Surgical site infection in clean and clean-contaminated cases. Indian J Med Microbiol 23:249–252 Khan MS, Rehman S, Ali MA, Sultan B, Sultan S (2008) Infection in orthopedic implant surgery, its risk factors and outcome. J Ayub Med Coll Abbottabad 20:23–25 Maksimovic’ J, Markovic’-Denic’ L, Bumbasirevic’ M, Markovic J, Viajinac H (2008) Surgical site infections in orthopedic patients: prospective cohort study. Croat Med J 49:58–65 Ibtesam KA, Ehssan AB (2010) Three months study of orthopaedic surgical site infections in an Egyptian University hospital. Int J Infect Control 6(1):25–27 Jain BK, Banerjee M (2013) Surgical site infections and its risk factors in orthopaedics: a prospective study in teaching hospital of central India. Int J Res Med 2(1):110–113
123
16. Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ (2006) The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br 88:943–948 17. Chen S, Anderson MV, Cheng WK, Wongworawat MD (2009) Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res 467(7):1670–1673 18. Richards JE, Kauffmann RM, Zuckerman SL, Obremskey WT, May AK (2012) Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery. J Bone Joint Surg Am 94(13):1181–1186 19. Turan A, Mascha EJ, Roberman D, Turner PL, You J, Kurz A et al (2011) Smoking and perioperative outcomes. Anesthesiology 114(4):837–846 20. Durand F, Berthelot P, Cazorla C, Farizon F, Lucht F (2013) Smoking is a risk factor of organ/space surgical site infection in orthopaedic surgery with implant materials. Int Orthop 37(4):723–727 21. Ercole FF, Franco LM, Macieira TG, Wenceslau LC, de Resende HI, Chianca TC (2011) Risk of surgical site infection in patients undergoing orthopedic surgery. Rev Lat Am Enfermagem 19:1362–1368 22. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS (2006) Surgical infection in the elderly following orthopaedic surgery: risk factors and outcomes. J Bone Joint Surg Am 88:1705–1712
ORIGINAL ARTICLE
Epidemiology and risk factors for surgical site infections in patients requiring orthopedic surgery Ravi Kant Jain • Rajeev Shukla • Pankaj Singh Ravindra Kumar
•
Received: 14 February 2014 / Accepted: 23 April 2014 Ó Springer-Verlag France 2014
Abstract Introduction Surgical site infection (SSI) is the most common complication following surgical procedures. The aim of this study was to determine the incidence and associated risk factors of SSI in orthopedic patients admitted in a tertiary care center. Materials and methods Data were collected which focused on demographic details, lifestyle factors, diagnosis, surgical procedure, duration of surgery, prophylactic antibiotics, postoperative antibiotics and comorbidity obtained from the patients hospital records. Univariate analysis and multinomial logistic regression tests were performed to identify independent risk factors for orthopedic incisional SSIs. Results The overall rate of SSI was 2.1 %. Univariate analysis showed diabetes, smoking and duration of hospital stay to be significantly associated with patients in whom SSI developed than in uninfected control patients. Independent risk factors for SSI that were identified by multinomial logistic regression were diabetes (OR 3.953) and smoking (OR 38.319). Conclusion Diabetes and smoking were independent risk factors for SSIs. Therefore, it is recommended to tightly regulate blood glucose levels and stop smoking to reduce the SSIs.
R. K. Jain (&) R. Shukla P. Singh Department of Orthopedics, Sri Aurobindo Medical College and PG Institute, Indore 453111, Madhya Pradesh, India e-mail: [email protected] R. Kumar Central Research Laboratory, Sri Aurobindo Medical College and PG Institute, Indore 453111, Madhya Pradesh, India
Keywords factors
Surgical site infection Orthopedics Risk
Introduction Surgical site infections (SSIs) are ill-fated and bothersome complications after surgeries, usually leading to increased morbidity, mortality, length of hospital stay and health care costs [1, 2]. Increased morbidity and mortality are associated with SSI, ranging from wound discharge associated with superficial skin infection to life-threatening conditions such as severe sepsis [3, 4]. In orthopedic wards, SSIs represent approximately 20 % of the overall nosocomial infections [5]. Orthopedic SSIs prolong hospital stays ranging from 12 to over 20 days, approximately double rehospitalization rates, and increase health care costs by[300 % [6, 7]. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and decreased patients’ quality of life [6, 7]. Staphylococcus aureus is a commonly isolated organism in SSI, accounting for 15–20 % of SSI occurring in hospital; other organisms regularly isolated from SSIs include gram-negative bacilli, Coagulase-negative staphylococci, Enterococcus spp. and Escherichia coli [3, 4]. Methicillinresistant S. aureus (MRSA) is an increasingly important pathogen that causes more than 50 % of S. aureus hospital acquired infections in the US and Europe and presents challenges to treatment due to multiple antibiotic resistance [8]. A major 30–50 % of antimicrobials prescribed in hospital practice are for surgical prophylaxis to prevent postoperative wound infection. A reduction in the infection rate to a minimal level could have significant benefits in terms of both patient comfort and medical resources used [9].
123
Eur J Orthop Surg Traumatol
For reduction in incidence of orthopedic SSIs, there should be proper knowledge of major risk factors in that particular community and hospital. The risk factor can be patient-related i.e., increased age, diabetes mellitus, obesity, previous surgical infection, poor nutrition, etc. and surgery-related i.e., operation duration, wound classification, excessive blood loss and antibiotic prophylaxis. Therefore, aim of the present study was to identify the major risk factors associated with orthopedic SSI and to find out the frequency of microorganism associated with SSI so that early prophylactic treatment policy can be adopted.
Materials and methods This retrospectively observational study reviewed the medical records of all 8,805 patients who had orthopedic surgeries in a tertiary care hospital between January 2011 and December 2013, among which, 1,252 patients were excluded because of various reasons including the presence of an infection prior to surgery, a contaminated surgical wound or the need for further surgery within 72 h, thus leaving 7,553 patients who were finally included in the present study. SSIs were identified by orthopedic surgeons in 159 patients based on the Centers for Disease Control and Prevention’s surgical site criteria published in 1999. Three hundred age- and sex-matched patients without any SSI were randomly selected for statistical analysis.
Results Out of 7,553 orthopedic patients requiring surgery, 159 (2.1 %) patients develop SSI during the study period. Since the number of orthopedic patients without any SSI is very large, we have a chosen 300 randomly selected age- and sex-matched orthopedic patient without any SSI as a control group for further analysis. The mean age of patient with SSI and control group was 36.28 ± 19.9 and 37.38 ± 16.3 years, respectively. The male to female ratio in SSI group was almost 3.2 (121:38). In the present study, 72 (45.9 %) of the 159 clinical SSIs were culture negative. Out of 87 culture positive samples, the most common bacteria isolated was S. aureus (28.9 %) followed by Pseudomonas aeruginosa (9.4 %), Klebsiella pneumonia (5.7 %), Mycobacteria (3.8 %), Coagulasenegative staphylococcus (1.3 %), MRSA (1.3 %) and others (4.3 %). We found a significant association of SSIs with smoking, diabetes mellitus, hypertension and duration of hospital stay. We did not observe any significant association with alcohol intake, socioeconomic status and duration of surgery (Table 1). Multinomial logistic regression analysis was done to identify independent risk factors for orthopedic incisional SSIs. Diabetes mellitus and smoking had a clear association with the occurrence of infection. Other variable that independently associated with an increased risk of orthopedic SSIs was duration of hospital stay and alcohol intake (Table 2).
Data collection Data comprising patient-related and surgery-related information were collected from the medical records using a standardized data collection independently by two investigators. Patient-related information includes age, gender, weight, underlying disorders, diagnosis, history of smoking and/or alcohol abuse previous surgeries and others. Surgery-related information covers length of hospitalization, length of preoperative stay, prosthetic implant used, type of operative procedure, duration of operation, use of antibiotics, etc. Statistical analysis To check the association between SSIs and risk factors, Fisher exact test was performed for categorical variables, and student t test was performed for continuous variables. Multinomial logistic regression was used to identify independent risk factors for SSIs. A two-tailed P \ 0.05 was considered significantly in all statistical tests. All statistical analyses were performed using SPSS software version 20.0 (SPSS Inc, Chicago, IL, USA).
123
Discussion Infections in orthopedic patients are the common cause of morbidity. Infections occur even though surgeons take meticulous aseptic precautions during surgery, and patients are strictly managed before and after surgery. The incidence rate of SSI was 2.1 % in the present study. Our study is similar to study done by Li et al. [10] on 2,061 patients requiring orthopedic surgery in China. However, our study has disparity from other previous reports from developing countries including India that shows the rate of SSIs ranging from 4.2 to 22.7 % [11–15]. Staphylococcus aureus was predominant causative organism in the present study. Khan et al. [12], Maksimovic’ et al. [13], Ibtesam et al. [14] also reported S. aureus as a main culprit for SSIs. However, Li et al. [10], Phillips et al. [16] reported Coagulase-negative staphylococci as a most common microorganism causing SSIs. Diabetes mellitus can increase infection rate and impair wound healing. Poorly controlled diabetes adversely affects the ability of leukocytes to destroy invading
Eur J Orthop Surg Traumatol Table 1 Univariate analysis of different parameters in SSIs and control group
Parameter
SSI
Control
P value
OR
95 % CI -6.836 to 0.716
Age (years)
36.28 ± 19.9
39.34 ± 19.4
0.112
–
Sex (male)
121 (76.1 %)
229 (76.0 %)
0.981
1.006
0.6407–1.578
Duration of surgery (min)
85.27 ± 41.25
81.7 ± 39.8
0.373
–
-4.426 to 11.352
Duration of hospital stay (days)
23.24 ± 16.2
19.70 ± 13.4
0.013
–
0.749–6.329
Diabetes mellitus
25 (15.7 %)
23 (7.7 %)
0.012
2.247
1.230–4.106
Hypertension
18 (11.1 %)
30 (10 %)
0.7797
1.149
0.618–2.134
Smoking
57 (35.8 %)
24 (8.0 %)
\0.0001
6.426
3.789–10.900
Alcohol
57 (35.8 %)
96 (32 %)
0.405
1.188
0.7921–1.780
23 (14.5 %)
45 (15 %)
0.098
–
–
Socio-economic status Lower Upper lower
37 (23.3 %)
97 (32.3 %)
Lower middle
99 (62.3 %)
158 (52.7 %)
Upper middle
0 (0 %)
0 (0 %)
Upper
0 (0 %)
0 (0 %)
Table 2 Multinomial logistic regression analysis between SSIs and control group Parameters
B
P value
Age
-0.012
0.056
0.989
0.977–1.000
Sex (male)
-0.449
0.066
0.607
0.357–1.033
Duration of surgery
0.000
0.906
1.000
0.994–1.005
Number of days in hospital
0.022
0.004
1.023
1.007–1.039
Diabetes
1.374
0.002
3.953
1.664–9.390
Smoke
3.646
0.000
38.319
14.109–104.076
Hypertension
0.471
0.269
1.602
0.694–3.695
-2.235
0.000
0.107
0.043–0.268
Lower
-0.121
0.711
0.886
0.469–1.676
Upper lower
-0.584
0.028
0.558
0.331–0.938
Alcohol
OR
95 % CI
Some studies found that the longer surgery length was associated with a higher SSIs risk [10, 22], whereas other studies showed no relevance between them [12, 19]. Our study also shows that there is no relationship between the surgical operation time and incidence of SSIs. In conclusion, SSIs are unavoidable in different orthopedic procedures although all aseptic precautions are taken. The possible risk factors that can be characterized are presence of diabetes, smoking and duration of hospital stay, etc. Therefore, it is recommended to tightly regulate blood glucose levels and stop smoking to reduce the SSIs. Conflict of interest
None.
Socioeconomic status
bacteria and to prevent the harmful proliferation of usually benign bacteria present in the healthy body. About 2.5 times higher risk of postoperative wound infection in diabetic patients than nondiabetic was observed in the present study (Table 1). This agrees with the findings of other researchers who all reported increased predisposition of diabetes to surgical wound infection in their different centers [17, 18] Therefore, patients with diabetes mellitus require tight glucose control before surgery. Smokers have a higher incidence of infectious and noninfectious healing complications after surgery compared with nonsmokers across all surgical specialties [19, 20]. We also found that smokers develop SSIs about 6.4 times higher than nonsmokers (Table 1). The higher surgical operation duration increased the tissue exposure time, increased surgical team technical errors and decreased organism’s systemic defenses [21].
References 1. Mangram AJ, Horan TC, Pearson ML, Silver CL, Jarvis WR (1999) Guideline for prevention of surgical site infection, 1999: hospital infection control practices advisory committee. Infect Control Hosp Epidemiol 20:250–278 2. de Lissovoy G, Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB (2009) Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 37:387–397 3. Anderson DJ, Kaye KS (2009) Staphylococcal surgical site infections. Infect Dis Clin North Am 23:53–72 4. Owens CD, Stoessel K (2008) Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect 70:3–10 5. Saadatian-Elahi M, Teyssou R, Vanhems P (2008) Staphylococcus aureus, the major pathogen in orthopaedic and cardiac surgical site infections: a literature review. Int J Surg 6:238–245 6. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ (2002) The impact of surgical site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 23:183–189 7. Bachoura A, Guitton TG, Smith RM, Vrahas MS, Zurakowski D, Ring D (2011) Infirmity and injury complexity are risk factors for
123
Eur J Orthop Surg Traumatol
8.
9. 10.
11.
12.
13.
14.
15.
surgical-site infection after operative fracture care. Clin Orthop Relat Res 469:2621–2630 Dulon M, Haamann F, Peters C, Schablon A, Nienhaus A (2011) MRSA prevalence in European healthcare settings: a review. BMC Infect Dis 11:138 Nandi PL, Rajan SS, Mak KC, Chan SC, So YP (1999) Surgical wound infection. Hong Kong Med J 5:82–86 Li GQ, Guo FF, Ou Y, Dong GW, Zhou W (2013) Epidemiology and outcomes of surgical site infections following orthopedic surgery. Am J Infect Control 41:1268–1271 Lilani SP, Jangale N, Chowdhary A, Daver GB (2005) Surgical site infection in clean and clean-contaminated cases. Indian J Med Microbiol 23:249–252 Khan MS, Rehman S, Ali MA, Sultan B, Sultan S (2008) Infection in orthopedic implant surgery, its risk factors and outcome. J Ayub Med Coll Abbottabad 20:23–25 Maksimovic’ J, Markovic’-Denic’ L, Bumbasirevic’ M, Markovic J, Viajinac H (2008) Surgical site infections in orthopedic patients: prospective cohort study. Croat Med J 49:58–65 Ibtesam KA, Ehssan AB (2010) Three months study of orthopaedic surgical site infections in an Egyptian University hospital. Int J Infect Control 6(1):25–27 Jain BK, Banerjee M (2013) Surgical site infections and its risk factors in orthopaedics: a prospective study in teaching hospital of central India. Int J Res Med 2(1):110–113
123
16. Phillips JE, Crane TP, Noy M, Elliott TS, Grimer RJ (2006) The incidence of deep prosthetic infections in a specialist orthopaedic hospital: a 15-year prospective survey. J Bone Joint Surg Br 88:943–948 17. Chen S, Anderson MV, Cheng WK, Wongworawat MD (2009) Diabetes associated with increased surgical site infections in spinal arthrodesis. Clin Orthop Relat Res 467(7):1670–1673 18. Richards JE, Kauffmann RM, Zuckerman SL, Obremskey WT, May AK (2012) Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery. J Bone Joint Surg Am 94(13):1181–1186 19. Turan A, Mascha EJ, Roberman D, Turner PL, You J, Kurz A et al (2011) Smoking and perioperative outcomes. Anesthesiology 114(4):837–846 20. Durand F, Berthelot P, Cazorla C, Farizon F, Lucht F (2013) Smoking is a risk factor of organ/space surgical site infection in orthopaedic surgery with implant materials. Int Orthop 37(4):723–727 21. Ercole FF, Franco LM, Macieira TG, Wenceslau LC, de Resende HI, Chianca TC (2011) Risk of surgical site infection in patients undergoing orthopedic surgery. Rev Lat Am Enfermagem 19:1362–1368 22. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS (2006) Surgical infection in the elderly following orthopaedic surgery: risk factors and outcomes. J Bone Joint Surg Am 88:1705–1712
