Volume 10, Number 1, 2009
© Mary Ann Liebert, Inc.
Trends in Postoperative Sepsis:
Are We Improving Outcomes?*
Todd R. Vogel, Viktor Y. Dombrovskiy, and Stephen F. Lowry
Background and Purpose: Each year, as many as two million operations are complicated by surgical site infec-
tions in the United States, and surgical patients account for 30% of patients with sepsis. The purpose of this
study was to determine recent trends in sepsis incidence, severity, and mortality rate after surgical procedures
and to evaluate changes in the pattern of septicemia pathogens over time.
Methods: Analysis of the 1990–2006 hospital discharge data from the Healthcare Cost and Utilization Project
(HCUP) State Inpatient Databases (SID) for New Jersey. Patients ?18 years who developed sepsis after surgery
were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes as
defined by the Patient Safety Indicator “Postoperative Sepsis” developed by the Agency for Healthcare Re-
search and Quality (AHRQ). Severe sepsis was defined as sepsis complicated by organ dysfunction.
Results: A total of 1,276,451 surgery discharges (537,843 elective [42.1%] and 738,608 non-elective [57.9%] pro-
cedures) were identified. After elective surgery, 5,865 patients (1.09%) developed postoperative sepsis, of whom
2,778 (0.52%) had severe sepsis. The incidence of postoperative sepsis after elective surgery increased from
0.67% to 1.74% (p ? 0.0001) and severe sepsis after elective surgery from 0.22% to 1.12% (p ? 0.0001). The sep-
sis mortality rate for elective procedures showed no significant change over time. The proportion of severe sep-
sis after elective cases increased from 32.9% to 64.6% (p ? 0.0002). The rates of postoperative sepsis (4.24%) and
severe sepsis (2.28%) were significantly greater for non-elective than for elective procedures (p ? 0.0002). Non-
elective surgical procedures had a significant increase in the rates of postoperative sepsis (3.74% to 4.51%) and
severe sepsis (1.79% to 3.15%) over time (p ? 0.0001) with the proportion of severe sepsis increasing from 47.7%
to 69.9% (p ? 0.0002). The in-hospital mortality rate after non-elective surgery decreased from 37.9% to 29.8%
(p ? 0.0001).
Conclusions: Sepsis and death were more likely after non-elective than elective surgery. Sepsis and severe sep-
sis has increased significantly after elective and non-elective procedures over the last 17 years. The hospital
mortality rate was reduced significantly after non-elective surgery, but no improvements were found for elec-
tive surgery patients who developed sepsis. Disparities in age, sex, and ethnicity and the development of post-
operative surgical sepsis were found. Population-based studies may assist in defining temporal trends, dis-
parities, and outcomes in sepsis not elucidated in smaller studies.
to two million are complicated by surgical site infections
[1–3]. Sepsis is an extreme manifestation of the infectious
process that is associated with increased resource utilization
and poor outcome. Surgery patients can be defined as a high-
risk group for developing sepsis, as procedures evoke sub-
stantial metabolic, hematologic, and immunologic responses
. The immune function after surgery may be transformed
ORE THAN 40 MILLION major surgical operations are per-
formed annually in the United States of which 800,000
substantially by perioperative bacterial infection, hemor-
rhage, blood transfusion, or anesthesia up to severe sup-
pression that promotes sepsis [4–8].
In the United States, the incidence of sepsis during the last
decades has increased considerably and has been accompa-
nied by a significant increase in the disease severity [9–11].
Despite the reduction in the disease case fatality rate over
time, sepsis remains one of the leading causes of death in the
United States . Surgical patients account for approxi-
The Surgical Outcomes Research Group, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey.
*Presented at the 28thAnnual Meeting of the Surgical Infection Society, Hilton Head Island, South Carolina, May 8, 2008.
VOGEL ET AL.72
mately 30% of all sepsis patients , and epidemiologic in-
vestigation of sepsis incidence and death after surgical pro-
cedures may help to define patient populations at greatest
risk and characterize temporal changes in sepsis and out-
comes. Most of the current data on post-surgical sepsis are
based on analysis from single institutions and small geo-
graphic areas, which makes their generalizability difficult
[14–20]. We evaluated trends in incidence, severity, mortal-
ity rate, and associated pathogens of sepsis after surgical pro-
cedures on a population level.
Patients and Methods
Data for this study were collected from the New Jersey
State Inpatient Databases (SID) from 1990 to 2006. The SID
is a publicly available database, developed as a part of the
Healthcare Cost and Utilization Project (HCUP) and spon-
sored by the Agency for Healthcare Research and Quality
(AHRQ) . The New Jersey SID includes inpatient dis-
charge abstracts from the acute care community hospitals in
the state that are collected annually by the state Department
of Health and Senior Services. They contain clinical and non-
clinical information on hospitalized patients with all types
of insurance and the uninsured, and cover annually more
than one million hospitalizations with several hundred char-
We selected patients 18 years and older who were admit-
ted to the hospital for surgical procedures. To identify sur-
gical patients, we used all International Classification of Dis-
eases, Ninth Revision, Clinical Modification (ICD-9-CM)
operating room procedure codes and surgical discharge Di-
agnosis-Related Groups (DRGs).
To identify surgical patients developing sepsis, the Patient
Safety Indicator “Postoperative Sepsis” (PSI 13) was utilized
. Patient Safety Indicator 13 was designed to identify sep-
sis as a complication. The AHRQ and the Stanford-Univer-
sity of California-San Francisco Evidence-based Practice
Center have developed Patient Safety Indicators (PSIs).
These indicators were developed after a comprehensive lit-
erature review, analysis of ICD-9-CM codes, review by a
clinician panel, implementation of risk adjustment, and em-
pirical analyses. The PSIs focus on potentially preventable
instances of complications and other iatrogenic events dur-
ing hospitalization. They are tools to identify potential ad-
verse events and are screening tools for highlighting areas
in which quality should be investigated and for case finding
and tracking and monitoring patient safety events. Among
20 hospital-level indicators, eight are related to surgical dis-
charges. One of these indicators, PSI 13 was utilized to iden-
tify sepsis as a complication. Patient Safety Indicators are
particularly applicable to surgical patients, as they are more
homogeneous than medical patients, making it easier to ac-
count for case mix.
Observations with postoperative sepsis had the following
ICD-9-CM diagnosis codes in any secondary position (sug-
gesting a complication from the surgical procedure) for the
diagnosis codes: Streptococcal septicemia (038.0), staphylo-
coccal septicemia unspecified (038.10), Staphylococcus aureus
septicemia (038.11), Other staphylococcal septicemia
(038.19), pneumococcal septicemia (038.2), septicemia due to
anaerobes (038.3), gram-negative organism unspecified
(038.40), Haemophilus influenzae (038.41), Escherichia coli
(038.42), Pseudomonas (038.43), Serratia (038.44), septicemia
due to other gram-negative organisms (038.49), other speci-
fied septicemias (038.8), unspecified septicemia (038.9), sep-
tic shock (785.52), other shock without mention of trauma
(785.59), systemic inflammatory response syndrome due to
infectious process without organ dysfunction (995.91), or sys-
temic inflammatory response syndrome due to infectious
process with organ dysfunction (995.92).
To identify major organ dysfunction, the following ICD-
9-CM diagnosis codes in any secondary position for the di-
agnosis code were used: cardiovascular failure (785.50,
785.51, 785.59, 458.0, 458.8, 458.9, 796.3, 427.5), respiratory
failure (518.81, 518.82, 786.09, 799.1), acute renal failure
(584.5, 584.6, 584.7, 584.8, 584.9), acute hepatic failure (570,
572.2, 573.4), coagulation failure (286.6, 286.9, 287.4, 287.5),
and central nervous system failure (293.0, 348.1, 348.3,
In accordance with the PSI 13 requirements, we excluded
from the analysis all patients with preexisting sepsis or in-
fection, with any ICD-9-CM code for immunocompromised
state or cancer, with the Major Diagnostic Categories (MDC)
code 14 (Pregnancy and Childbirth), and with hospital length
of stay of less than four days. These restrictions increase the
chance that a person developed sepsis as a result of the sur-
gical procedure. In addition, among all septic patients, we
selected a subgroup of those with severe sepsis defined as
sepsis complicated by organ dysfunction . Classification
of an operation as elective or non-elective was based on the
HCUP variable for admission type.
Data were analyzed with SAS 9.1 software (SAS Institute,
Cary, NC). We used demographic characteristics of patients
(age, sex, and race), principal and eight secondary diagnoses,
principal and seven secondary procedures, admission source
and type, disposition of patient at discharge, and calendar
year. The rate of postoperative sepsis was defined as the
number of postoperative sepsis cases divided by the num-
ber of patients with surgical procedures, expressed as a per-
centage. To evaluate the severity of the disease, we calcu-
lated the percentage of severe sepsis cases among all sepsis
cases. The rate of hospital mortality for postoperative sepsis
was calculated as the number of fatal surgical sepsis cases in
the hospitals divided by the total number of hospitalized
surgical patients with sepsis expressed as a percentage. To
test the difference in estimates between various groups we
used the Student t-test for continuous variables and chi-
square analysis for categorical variables. The z ratio with p
value for the difference between two independent propor-
tions was utilized to compare two groups with results pre-
sented as percentages. The Cochran-Armitage trend test was
employed initially to analyze changes in the rates of post-
operative sepsis and its mortality rate from 1990–2006. Tak-
ing into account the changes in the age structure of popula-
tion in the country over the study period, we adjusted the
rates of sepsis incidence and death with the method of di-
rect standardization and computed direct standardized rate
OUTCOMES IN POSTOPERATIVE SEPSIS73
with the standard error (SE) of this rate . The structure
of the population of hospitalized surgical patients in the State
of New Jersey in 2000 was used as a standard in computing
standardized rates of sepsis incidence. Calculating the stan-
dardized rates of death, we used for the same purpose a
structure of septic surgical patients hospitalized in the year
2000. Trends in age-adjusted rates were evaluated with lin-
ear regression analysis. All reported p values are two-sided;
p ? 0.05 was considered significant.
A total of 1,276,451 surgery discharges that met the inclu-
sion and exclusion criteria for our study were identified in
the New Jersey acute care hospitals from 1990 to 2006.
Among all surgical patients, 42.1% were admitted to the hos-
pital electively and 57.9% non-electively. Demographic and
clinical characteristics of patients undergoing surgical pro-
cedures of both categories, including those who developed
sepsis, are displayed in Table 1. Overall, 2.9% of all surgical
procedures were complicated by sepsis. Patients undergoing
non-elective procedures developed sepsis more often than
those having elective procedures (4.2% and 1.1%, respec-
tively; p ? 0.0002).
From 1990 to 2006, the rates of postoperative sepsis in New
Jersey increased significantly (Table 2; Fig. 1) for both non-
elective (from 3.74% to 4.51%; p ? 0.0001) and elective (from
0.67% to 1.74%; p ? 0.0001) surgery. The proportion of cases
of severe sepsis after non-elective procedures increased from
47.7% to 69.9% (p ? 0.0002) and almost doubled after elec-
tive procedures (from 32.9% to 64.6%; p ? 0.0002). As well,
the rates of severe sepsis increased 1.8 times for non-elective
admissions (from 1.79% to 3.15%; p ? 0.0001) and more than
five times (from 0.22% to 1.12%; p ? 0.0001) for elective ad-
missions (Table 2; Fig. 2).
Evaluating trends between 1990 and 2006, we found that
the hospital mortality rate after non-elective surgery for pa-
tients developing sepsis was reduced significantly, from
37.9% to 29.8% (p ? 0.0001) (Table 2, Fig. 3). Evaluation of
elective procedures did not show a significant decrease in
the postoperative sepsis mortality rate over time (p ? 0.097).
Trend analysis showed a decreasing hospital mortality rate
for severe sepsis in both groups (Table 2; Fig. 4): From 55.4%
to 38.0% (p ? 0.0001) after non-elective procedures and from
52.2% to 34.4% (p ? 0.0001) after elective procedures.
In the total cohort of patients with sepsis, 52.7% developed
severe sepsis. The proportion of severe sepsis cases after non-
elective procedures (53.7%) was significantly greater than af-
ter elective procedures (47.4%; p ? 0.0002). The systems most
affected with organ dysfunction were the respiratory, car-
diovascular, and renal. The overall sepsis mortality rate in
the research cohort was 31.7%, and after non-elective surgi-
cal procedures (32.7%), it was significantly greater than af-
ter elective procedures (26.6%; p ? 0.0002). In the severe sep-
sis cases, the mortality rate was higher (45.7%; p ? 0.0002);
it was still greater for non-elective procedures (46.2%) than
for elective surgery (42.4%; p ? 0.0002).
There was a significant and steady increase in the rates of
postoperative sepsis associated with age. Only 1.75% of pa-
tients younger than 50 years developed sepsis, whereas oc-
TABLE 1.CHARACTERISTICS OF SURGICAL PATIENTS
All surgical proceduresElectiveNon-elective
CharacteristicN Sepsis (%)N SepsisN Sepsis
Age (years )
Central nervous system
Including severe sepsis
1,276,45137,171 (2.9) 537,8435,865 (1.1)738,608 31,306 (4.2)
0 27 17
VOGEL ET AL.74
togenarians had a rate of sepsis of 4.21% (p ? 0.0002). Inter-
estingly, this trend predominated among patients having
elective procedures (3.2-fold increase: From 0.61% to 1.97%;
p ? 0.0002) whereas after non-elective surgical procedures,
the increase was less extensive (1.7-fold: From 2.77% to
4.86%; p ? 0.0002) and in patients 65–79 years of age, the
rates of postoperative sepsis did not differ from that in oc-
Male patients were more likely to have postoperative sep-
sis than female patients (odds ratio [OR] ? 1.17; 95% confi-
dence interval [CI] 1.15, 1.20), and this difference was greater
after elective procedures (OR ? 1.37; 95% CI 1.30, 1.44) than
after non-elective surgery (OR ? 1.10; 95% CI 1.08, 1.13).
Racial disparities in the occurrence of postoperative sepsis
were noted. We found the lowest rate of surgical sepsis in
white patients (2.77%), whereas black patients had the high-
est rate (3.82%; p ? 0.0002). A similar distribution was found
after both elective and non-elective procedures.
We compared patterns of the septicemia pathogens in sur-
gical patients with elective and non-elective surgical proce-
dures. Compared with the latter, in the whole elective sub-
group, there were lower rates of septicemia attributable to
Streptococcus (p ? 0.0443), Pneumococcus (p ? 0.0043), and E.
coli (p ? 0.0002), whereas the rates of septicemia caused by
Pseudomonas and other specified and unspecified septicemias
were increased (p ? 0.0159 and p ? 0.0002, respectively).
The rates of septicemia attributed to anaerobes and Staphy-
lococcus in the two subgroups were similar (p ? NS).
Trend analysis was conducted of the rates of septicemia
from 1990 to 2006 according to the particular organism
coded. In the subgroup of the elective surgical procedures,
a significant increase in the rates of the streptococcal sep-
TABLE 2.INCIDENCE AND MORTALITY RATE FOR POSTOPERATIVE SEPSIS IN NEW JERSEY, 1990–2006
Incidence, %Mortality, %
SepsisSevere sepsis Sepsis Severe sepsis
YearElective N/electiveElective N/electiveElective N/electiveElective N/elective
N/elective ? non-elective.
Age-adjusted rates of postoperative sepsis in New Jersey, 1990–2006. Error bar ? standard error.
OUTCOMES IN POSTOPERATIVE SEPSIS75
ticemia (p ? 0.0039) and staphylococcal septicemia (p ?
0.0041) was discovered. The rates of septicemia caused by E.
coli, Pseudomonas, and anaerobes were unchanged over time.
Among patients with surgical procedures who were admit-
ted to the hospital non-electively, we found a significant neg-
ative trend in the rates of septicemias attributed to staphy-
lococci (p ? 0.0001), anaerobes (p ? 0.0451), Pseudomonas
(p ? 0.0298), and E. coli (p ? 0.0001).
More than 40 million surgical procedures are performed
annually in the United States, and sepsis remains a major
postoperative complication [1–3,25]. Surgical sepsis accounts
for approximately 30% of all sepsis patients . The ma-
jority of published data on postoperative sepsis are derived
from single institutions. Although these studies are
important, they offer limited information about the demog-
raphy of sepsis or temporal changes. As well, the generaliz-
ability of small series may be difficult. The use of population
data for postoperative surgical sepsis is not well represented
in the literature, although there have been multiple studies
evaluating population data for the occurrence of medical
These data have demonstrated that trends in the age-ad-
justed rates of postoperative sepsis and the proportion of se-
vere sepsis among all sepsis cases has increased significantly
for both elective and non-elective procedures over the 17-
year study period. During the study period, the overall hos-
pital mortality rate among surgical sepsis patients with non-
elective admission was reduced. Of concern is that elective
surgical cases failed to show a decrease in age-adjusted rates
of mortality for postoperative sepsis. Previous population
data evaluating all cases of sepsis (medical and surgical)
have reported that the incidence of sepsis and the number
of sepsis-related deaths are increasing, although the overall
mortality rate among patients with sepsis is declining .
This population-level study demonstrates an increase in
the rate of sepsis for elective surgical procedures over time
with no significant improvements in the mortality rate. The
proportion of cases of severe sepsis also was found to in-
crease for elective surgery, from 32.9% to 64.6%. This signif-
icant increase suggests greater severity of sepsis as well as a
higher incidence over time. The reasons for this increase in
Age-adjusted rates of postoperative severe sepsis in New Jersey, 1990–2006. Error bar ? standard error.
Age-adjusted rates of mortality for postoperative sepsis in New Jersey, 1990–2006. Error bar ? standard error.
VOGEL ET AL.76
the rate and severity of sepsis after elective surgery remain
unclear, but may reflect changes in the elective operative case
mix over time. That is, more elective operations may be per-
formed as outpatient procedures or with short lengths of
stay, leaving sicker patients and those having more exten-
sive procedures in the in-patient surgery cohort.
This study also demonstrates differences in the incidence
of postoperative sepsis with age. Previous large population
studies have looked at global sepsis rates (medical and sur-
gical) and have demonstrated that the incidence of sepsis
was disproportionately increased in elderly adults, and age
was an independent predictor of death . The aged were
more likely to develop sepsis and severe sepsis after surgery
and had a higher mortality rate after developing sepsis. Pos-
sible reasons for this disparity may be more frequent co-mor-
bidities, institutionalization, declining performance status,
and age-associated immunosenescence with defects in im-
munologic function in the aged [28,29]. Further analysis is
needed to address procedures associated with sepsis in the
elderly, as the aged are the fastest-growing segment of the
U.S. population .
Sex differences in the occurrence of sepsis are suggested
by these data. We found that male patients were more likely
to have postoperative sepsis. Further focused studies as-
sessing sex disparities will be needed; we were not focused
on that subject in this project. Several studies have evaluated
the effect of sex and hormone concentrations on sepsis [31,
32], suggesting that sex may have a role in the development
of sepsis. Others have suggested that sex hormones play a
significant role in shaping the host response to trauma [33,
34]. Further analyses at a population level may help to iden-
tify procedures, co-morbidities, and other factors that influ-
ence the likelihood of developing postoperative sepsis.
These data also suggest disparities among ethnicities in
the incidence of postoperative sepsis. We have demonstrated
that the lowest rates of sepsis were in whites and the high-
est rates were in blacks. These disparities were seen with
similar distributions after elective and non-elective proce-
dures. Although other studies have evaluated the effect of
race on medical sepsis , there are few data evaluating
ethnicity and its influence on postoperative sepsis. The rea-
sons for these disparities remain unclear, but considerations
may be more co-morbidities in blacks, different access to
care, or physiological differences yet to be determined. Fur-
ther, more detailed evaluations of race and postoperative
sepsis are required.
With regard to the evaluation of pathogens associated
with sepsis, elective surgical procedures demonstrated a sig-
nificant increase in the rates of the streptococcal and staphy-
lococcal septicemias. This finding is supported by other pop-
ulation studies, which have shown that the nosocomial blood
stream infection rate in the hospital has nearly doubled in
the past 10 years, largely secondary to an increase in primary
staphylococcal bacteremia . As well, the epidemiology of
severe surgical site infection (SSI) in community hospitals
and the prevalence of methicillin-resistant S. aureus SSI has
increased significantly over the past years . The inpatient
S. aureus infection rate and the economic burden of S. aureus
infections for all U.S. hospitals increased substantially from
1998 to 2003 .
This study has several limitations. The New Jersey State
Inpatient Databases do not include patients in military hos-
pitals or Veterans Affairs medical centers. Moreover, the
administrative data originally were intended primarily for
determination of reimbursement, although there are reports
validating the use of administrative data for research pur-
poses [9,39]. In addition, the potential for inclusion bias
based on limited coding schemes for the many clinical enti-
ties cannot be entirely excluded. For this analysis, we se-
lected codes for systemic infection that were effective and
unchanged during the study period, and, therefore, the ad-
dition of new codes should not have affected our selection.
It is possible that there has been more thorough capture of
codes by institutions based on reimbursement over time and
greater emphasis on capturing sepsis events. Although the
code scheme remained constant throughout the study, there
may be upcoding by the institutions, and this cannot be eval-
uated from the dataset. We assume this change to have been
slow over time and unlikely to affect the findings for the
severity of sepsis.
We realize that more elective operations may now be per-
formed on an outpatient and 23-hour admission basis, leav-
ing patients who are sicker and are having more complex
procedures in the in-hospital surgery cohort. We also ac-
Age-adjusted rates of mortality for postoperative severe sepsis in New Jersey, 1990–2006. Error bar ? standard
knowledge that there is a trade-off in using administrative
data on hundreds of thousands of patients compared with
the use of smaller cohorts with more refined clinical infor-
mation. Although both types of studies have drawbacks and
strengths, we believe that administrative data provide valu-
able population-based information on trends and severity of
In conclusion, these population data have shown a signif-
icant increase in age-adjusted rates of postoperative sepsis
over time. Despite the higher incidence of sepsis, the over-
all mortality rate improved, perhaps secondary to progress
in surgical critical care, greater utilization of surgical inten-
sivists, or alterations in the antibiotics or strategies em-
ployed. Of significant concern is the lack of advances in the
elective surgery cohort. Elective surgery had the greatest in-
creases in sepsis rates as well as the greatest increases in the
proportion of severe sepsis cases. Elective surgery also failed
to show a decrease in age-adjusted rates of death for post-
operative sepsis over time. Directions for future research us-
ing population data for postoperative sepsis may include the
analysis of the specific procedures associated with sepsis and
the focused evaluation on the various racial and sex dispar-
ities in the development of postoperative sepsis. These data
may also serve to track the effectiveness of care and func-
tion as hypothesis generating to initiate future studies fo-
cused on improvement of surgical outcomes.
Author Disclosure Statement
No competing financial interests exist.
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Address reprint requests to:
Dr. Todd R. Vogel
Division of Vascular Surgery
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
One Robert Wood Johnson Pl.—MEB-541
New Brunswick, NJ 08903-0019
VOGEL ET AL. 78