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Review of the Microbiologic and Epidemiological Aspects of 20,007 Wounds

Carl A. Weiss III, MD; Catherine L. Statz, RN, MPH; Rachel A. Dahms; Michael J. Remucal; David L. Dunn, MD, PhD; Gregory J. Beilman, MD

Arch Surg. 1999;134:1041-1048.

Hypotheses  (1) Antibiotic restriction policies result in alteration of microbiologic features of surgical site infections (SSIs) and (2) reported SSI rates are underestimated when postdischarge surveillance is not included in SSI surveillance efforts.

Design  Retrospective analysis of prospectively collected SSI surveillance data.

Patients and Methods  We compared initial microbial isolates from SSIs between (1) January 1, 1993, and December 31, 1995, and (2) January 1, 1996, and December 31, 1998. Antibiotic restriction policies were implemented at Fairview-University Medical Center, Minneapolis, Minn, on March 1, 1995. For the combined periods (January 1, 1993, to December 31, 1998), we determined SSI rates for 20,007 operations according to the extent of bacterial contamination at surgery (wound class). Then, we analyzed SSI rates for 10,559 of these operations (selected based on availability of Anesthesia Society of America score and type of procedure) using the surgical wound risk index (wound class, Anesthesia Society of America score, and length of operation). We categorized SSI rates by 17 procedures for comparison with SSI rates reported by 286 hospitals that contributed data confidentially and voluntarily to the National Nosocomial Infections Surveillance System in 1998. We compared SSI rates with and without postdischarge surveillance.

Results  Coagulase-negative staphylococcus and group D enterococcus were the 2 most frequent isolates before and after antibiotic restriction policies were implemented. Candida albicans isolates decreased from 7.9% (1993-1995) to 6.5% (1996-1998; P=.46). Methicillin–resistant Staphylococcus aureus (1.8% of isolates) and vancomycin-resistant enterococcus (2.4% of isolates) organisms were first identified between 1996 and 1998. Our SSI rates were 2.6% for class I wounds, 3.6% for class II wounds, and 10.5% for class III/IV wounds; 53.9% of SSIs were identified after hospital discharge.

Conclusions  Antibiotic restriction policies did not alter the microbial spectrum of SSIs during the observation period. Reporting SSI rates in the absence of postdischarge surveillance dramatically underestimates actual SSI rates, especially in tertiary care hospitals that provide care for large populations of elderly and immunosuppressed patients.

From the Division of Surgical Infectious Disease (Mss Statz and Dahms and Mr Remucal) Department of Surgery (Drs Weiss, Dunn, and Beilman), University of Minnesota, Minneapolis.

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