Content uploaded by Md Quamar Azam
Author content
All content in this area was uploaded by Md Quamar Azam on Oct 11, 2016
Content may be subject to copyright.
Int Surg 2014;99:264–268
DOI: 10.9738/INTSURG-D-13-00251.1
Prevalence of Surgical Site Infection in
Orthopedic Surgery: A 5-year Analysis
Fahad A. Al-Mulhim
1
, Mohammed A. Baragbah
2
, Mir Sadat-Ali
1
, Abdallah S. Alomran
1
,
Md Q. Azam
1
1
Department of Orthopaedic Surgery, College of Medicine, King Fahd Hospital of the University, Al Khobar,
Saudi Arabia
2
King Abdulaziz Airbase Hospital, Dhahran, Saudi Arabia
Surgical site infection (SSI) is disastrous in orthopedic practice as it is difficult to rid the
bone and joint of the infection. This study was aimed to assess the prevalence of SSI in
orthopedic practice and to identify risk factors associated with surgical site infections.
All patients admitted to the orthopedic male and female wards between January 2006 and
December 2011 were included in the study group. The data, which were collected from
the medical charts and from the QuadraMed patient filing system, included age, sex, date
of admission, type of admission (elective versus emergency), and classification of
fractures. Analyses were made to find out the association between infection and risk
factors, the v
2
test was used. The strength of association of the single event with the
variables was estimated using Relative Risk, with a 95% confidence interval and P,0.05.
A total of 79 of 3096 patients (2.55%) were included: 60 males and 19 females with the
average age of 38.13 619.1 years. Fifty-three patients were admitted directly to the
orthopedic wards, 14 were transferred from the surgical intensive care unit, and 12 from
other surgical wards. The most common infective organism was Staphylococcus species
including Methicillin Resistant Staphylococcus aureus (MRSA), 23 patients (29.11%);
Acinetobacter species, 17 patients (21.5%); Pseudomonas species, 15 patients (18.9%); and
Enterococcus species, 14 patients (17.7%). Fifty-two (65.8%) had emergency procedures,
and in 57 patients trauma surgery was performed. Three (3.78%) patients died as a result
of uncontrolled septicemia. SSI was found to be common in our practice. Emergency
surgical procedures carried the greatest risk with Staphylococcus species and Acineto-
bacter species being the most common infecting organisms. Proper measures need to be
Corresponding author: Mir Sadat-Ali, MBBS, MS, FRCS, D Orth, PO Box 40071, King Fahd Hospital of the University, Al Khobar
31952, Saudi Arabia.
Tel.: þ966138820887 or þ966505848281; Fax: þ966138820887; E-mail: drsadat@hotmail.com
264 Int Surg 2014;99
undertaken to control infection rates by every available method; antibiotics alone may
not be sufficient to win this war.
Key Words: Surgical Site Infection – Orthopedic Surgery – Trauma
Surgical site infection (SSI) is defined as microbial
contamination of the surgical wound within 30
days of an operation or within 1 year after surgery if
an implant is placed in a patient.
1
It is estimated that
annual incidence of SSI in the United States is 1.07%;
with 8000 deaths directly related to SSI
2
and a
financial cost of treatment to $10 billion. The
problem of SSI is universal; in the United Kingdom,
the extra cost for each SSI is approximately E2500
(US $3394),
3
and the length of the hospital stay
increases between 5.8 and 17 extra days.
4
Surgical-
site infections cause increased morbidity, mortality,
extended hospital in-patient stays, and economic
burden to the hospital resources.
5–8
Many preventable causes of SSI have been
identified, and if proper measures are implemented,
the incidence could be reduced. Patients, surgeons,
and nurses, as well as operative room atmosphere
and instrumentation are prime areas of concern.
Various methods have been established to reduce
infections in implant surgery, but infection does
occur.
The washing of hands and maintaining basic
hygiene,
9
prophylactic antibiotics given at the
proper time and at the correct strength,
10
surgical
clothing,
11
and reducing the flow of staff in the
operating room
12–14
all contribute to lowering the
incidence of infection.
This study was aimed to assess the prevalence of
SSI in orthopedic practice at King Fahd Hospital of
the University, Al Khobar, and also to identify risk
factors associated with surgical site infections.
Patients and Methods
The data gathered arose from a retrospective chart
review of 3096 patients who underwent orthopedic
surgical procedure during January 2007 and De-
cember 2011 at King Fahd Hospital of the University,
a 500-bed tertiary care center in Al Khobar, Saudi
Arabia. Our main aim was to detect the occurrence
of SSI within 30 days of the surgical procedure. The
data, which were collected from the medical charts
and from the QuadraMed patient filing system
(QuadraMed Corporation, Reston, Virginia, USA),
included age, sex, date of admission, type of
admission (elective versus emergency) and classifi-
cation of fractures. The components of the National
Nosocomial Infections Surveillance (NNIS) system
surgical-patient risk index used in this study were
as follows:
1. A preoperative anesthesia risk scoring system as
per Anesthesia Society of America (ASA);
2. Gustillo wound classification (GWC); and
3. ‘‘T time,’’ defined as the 75th percentile of the
duration for each operative procedure.
As a standard practice prophylactic, intravenous
antibiotics were given on call to the operating room.
The infection was assessed by the infective organ-
ism, sensitivity of the antibiotics, and recovery. Any
additional days the patient stayed in the hospital
were calculated on the basis of standard discharge
after each such procedure. The incidence rate of SSI,
according to the different categories of the individ-
ual components of the index (ASA, GWC, and T
time), was calculated. The strength of the association
between each of these factors and the incidence rate
of SSI were estimated using the Goodman-Kruskal
Gcoefficient. A measure of association between 2
variables established on an ordinal level. Analyses
were made to find out the association between
infection and risk factors, the v
2
test was used. The
strength of association of the single event with the
variables was estimated using Relative Risk, with a
95% confidence interval and P,0.05.
Results
A total of 79 of 3096 patients who had orthopedic or
trauma operations contracted an SSI. The incidence
of SSI was 2.55%. There were 60 males and 19
females with an average age of 38.13 619.1 years.
The demographic data are given in Table 1. Fifty-
three patients were admitted directly to the ortho-
pedic wards, 14 were transferred from the surgical
intensive care unit and 12 from the surgical wards.
Infection was significantly higher in patients who
underwent an emergency procedure P,0.001.
Table 2 lists the procedures carried out, showing
that the majority were trauma. The average operat-
ing time was 151.7 644.5 minutes (range, 40–370
PREVALANCE OF SSI IN ORTHOPEDIC SURGERY AL-MULHIM
Int Surg 2014;99 265
minutes). Patients overstayed in the hospital owing
to infection for an average of 24.75 days (range, 3–
150 days). Sixty-two patients (78.4%) had various
complications, and 3 patients (3.79%) died directly
as a result of uncontrolled septicemia. Table 3 gives
the different organisms and the percentages.
The most common infective organism was Staph-
ylococcus species including Methicillin Resistant
Staphylococcus aureus (MRSA) in 23 patients
(29.11%), Acinetobacter species in 17 (21.5%), Pseudo-
monas species in 15 (18.9%), and Enterococcus species
in 14 (17.7%).
Sixty-one patients (77.21%) cultured a single
organism, 15 had 2 infecting organisms, and 3
patients cultured more than 2 organisms. In all
patients who had 2 or more organisms, Acinetobacter
species was the common organism.
Discussion
The incidence of SSI in the present study was 2.55%,
which is below the reported worldwide incidence of
2.6% to 41.9%.
15
Second, our study differs from the
literature in that SSI was more common in younger
patients, whereas studies reported SSI to be high in
patients of over 55 years of age. This could be
because the majority of our patients were operated
on due to trauma, and it has been reported that
preoperative soft-tissue damage is a major risk
factor for developing SSI.
16
The other independent
risk factors for patients developing SSI were having
an emergency operation and having prolonged
surgery. The majority of patients with infection
had an ASA score of 1, but other studies have
suggested that the higher the ASA score, the higher
the risk of infection.
16–18
The movement and number of staff in the
operating room is long known to influence the
incidence of SSI. In our patients, we have practiced
to reduce the staff in the operating room to essential
staff only, and this has shown that there was no
serious deep-seated infection post arthroplasty,
whereas during other types of surgery the entry
and exit of the staff was not controlled. The
incidence of SSI was significantly higher in trauma
surgery versus total joint arthroplasty (P,0.001).
There are apparent unintended differences in the
quality of care that exist between patients undergo-
ing joint arthroplasty or spinal surgery and those
undergoing trauma surgery. There could be a couple
of reasons for these differences. During total joint
replacement, scoliosis and other spine surgery
senior staff are available, while routine trauma
surgery is performed by junior staff. Last, because
of the gravity of infection in a patient with
arthroplasty, surgeons tend to extend extra care
while operating, and arthroplasty surgeons go the
extra mile to limit SSI on the basis of research,
19–20
and monitoring the quality of care.
21
Barring the
level of the surgeon, the other preventable differ-
ences cannot be justified.
There are limited data available to review with
regard to SSI in Saudi Arabian patients. Abdel-
Fattah
22
reported after a 12-month study of
nosocomial infection from a military hospital, the
Table 1 Demographic data
Number of operations 3096
Number of patients with SSI 79
Average age, y 38.13 619.1
Site of hospital admission
Orthopedic wards 53 (67%)
Intensive care units 14 (17.7%)
Surgical wards 12 (15.3%)
ASA score
ASA1 49 (62%)
ASA2 21 (26.6)
ASA3 9 (11.4%)
Type of surgery
Emergency 52 (65.8%)
Elective 27 (34.2%)
Table 2 Type of surgery
Intramedullary nailing 43
Plate and screws 14
Spinal trauma 5
Scoliosis 1
Spondylolisthesis 1
THR 2
TKR 4
Implant removal 1
Others 8
THR, Total hip replacement; TKR, Total knee replacement.
Table 3 Infective organisms
Staphylococcus aureus þMRSA 23
Acinetobacter sp 17
Pseudomonas sp 15
Enterococcus sp 14
Escherichia coli 3
Klebsiella sp 3
Serratia sp 2
Providencia stuartii 1
Stenotrophomonas 1
Proteus mirabilis 1
Burkhalderia 1
Peptospirosis sp 1
AL-MULHIM PREVALANCE OF SSI IN ORTHOPEDIC SURGERY
266 Int Surg 2014;99
incidence of SSI was 12.9%, whereas Khairy et al
23
reported an incidence of 6.8% after a prospective
study. In both studies, the incidence appears
higher than in our study. Even though the authors
did not specify the different specialties these
patients were taken. In the recent past, the
outbreaks of Acinetobacter infections, which occur
in intensive care units, have caused much concern
to health care providers, hospital administrators,
and patients at large. Trauma patients who are
admitted to the ICU initially always carry a risk of
infection, which they carry from the ICU to the
wards. In this series, the majority of the patients
who contracted an SSI and cultured Acinetobacter
species apparently had been admitted to the ICU,
which is the primary breeding ground for such
organisms. Our study shows that Acinetobacter
organisms are increasing their presence in the
orthopedic wards, and this needs to be controlled.
At present it appears that the morbidity and
mortality that they cause are enormous and
sometimes beyond the control of the treating
physicians.
Results
This study has some limitations as well as strengths.
It is limited in that we studied only the patients who
developed infection postoperatively. The study
would have had more strength if we gathered the
data of all 3096 patients who were operated on and
compared them with the infected group.
In conclusion, this study shows that the
incidence of SSI in orthopedics and trauma
patients is comparable with the reported incidence
in the literature. We believe that development of
SSI is a complex process, which is dependent on
several different factors related to the patient, the
surgical environment (such as the ICU), staff
involvement, and finally the surgical technique.
We were able to identify the areas that need to be
addressed to further reduce the incidence of SSI in
our patients.
References
1. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG.
CDC definitions of nosocomial surgical site infections, 1992: a
modification of CDC definitions of surgical wound infections.
Infect Control Hosp Epidemiol 1992;13(10):606–608
2. Scott RD II. The Direct Medical Costs of Healthcare-Associated
Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta,
GA: Centers for Disease Control and Prevention, 2009
3. Plowman R, Graves N, Griffin MA, Roberts JA, Swan AV,
Cookson B et al. The rate and cost of hospital-acquired
infections occurring in patients admitted to selected special-
ties of a district general hospital in England and the national
burden imposed. J Hosp Infect 2001;47(3):198–209
4. Geubbels EL, Mintjes–de Groot AJ, Van den Berg JM, de Boer
AS. An operating surveillance system of surgical site
infections in The Netherlands: results of the PREZIES national
surveillance network. Preventie van Ziekenhuisinfecties door
Surveillance. Infect Control Hosp Epidemiol 2000;21(5):311–318
5. Awad SS, Palacio CH, Subramanian A, Byers PA, Abraham P,
Lewis D et al. Implementation of a methicillin resistant
Staphylococcus aureus (MRSA) prevention bundle results in
decreased MRSA surgical site infections. Am J Surg 2009;
198(5):607–610
6. Weigelt JA, Lipsky BA, Tabak YP, Derby KG, Kim M, Gupta V.
Surgical site infections: causative pathogens and associated
outcomes. Am J Infect Control 2010;38(2):112–120
7. Fry DE. The economic costs of surgical site infection. Surg
Infect (Larchmt) 2002;3(suppl 1):S37–S43
8. Urban JA. Cost analysis of surgical site infections. Surg Infect
(Larchmt) 2006;7(suppl 1):S19–S22
9. Pittet D. Compliance with hand disinfection and its impact on
hospital acquired infections. J Hosp Infect 2001;48(suppl A):
S40–S46
10. Polk HC Jr, Christmas AB. Prophylactic antibiotics in surgery
and surgical wound infections. Am Surg 2000;66(2):105–111
11. Tammelin A, Ljungqvist B, Reinm ¨
uller B. Comparison of three
distinct surgical clothing systems for protection from air-borne
bacteria: a prospective observational study [abstract]. Patient
Saf Surg 2012 Oct 15;6(1):23
12. Ayliffe GA. Role of the environment of the operating suite in
surgical wound infection. Rev Infect Dis 1991;13(suppl 10):
S800–S804
13. Letts RM, Doermer E. Conversation in the operating theater as
a cause of airborne bacterial contamination. J Bone Joint Surg
Am 1983;65(3):357–362
14. Ritter MA. Operating room environment. Clin Orthop Relat Res
1999;369(369):103–109
15. Lilani SP, Jangale N, Chowdhary A, Daver GB. Surgical site
infection in clean and clean-contaminated cases. Indian J Med
Microbiol 2005;23(4):249–252
16. Bachoura A, Guitton TG, Smith RM, Vrahas MS, Zurakowski
D, Ring D. Infirmity and injury complexity are risk factors for
surgical-site infection after operative fracture care. Clin Orthop
Relat Res 2011;469(9):2621–2630
17. Maksimovi´
c J, Markovi´
c-Deni´
c L, Bumbaˇ
sirevi´
c M, Mar-
inkovi´
c J, Vlajinac H. Surgical site infections in orthopedic
patients: prospective cohort study. Croat Med J 2008;49:58–65
18. Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR,
Emori TG et al. Surgical wound infection rates by wound class,
operative procedure, and patient risk index. National Noso-
comial Infections Surveillance System. Am J Med 1991;91(3B):
152S–157S
PREVALANCE OF SSI IN ORTHOPEDIC SURGERY AL-MULHIM
Int Surg 2014;99 267
19. Lidwell OM, Lowbury EJL, Whyte W. Effect of ultraclean air in
operating rooms on deep sepsis in the joint after total hip or
knee replacement: a randomised study. Br Med J 1982;
285(6334):10–14
20. Lidwell OM, Lowbury EJL, Whyte W. Airborne contamination
of wounds in joint replacement operations: the relationship to
sepsis rates. J Hosp Infect 1983;4(2):111–131
21. K¨
arrholm J, Garellick G, Rogmark C, Herberts P. Swedish Hip
Arthroplasty Register Annual Report 2007. Gothenburg, Sweden:
Department of Orthopaedics Sahlgrenska University Hospital,
2007
22. Abdel-Fattah MM. Surveillance of nosocomial infections at a
Saudi Arabian military hospital for a one-year period. Ger Med
Sci 2005;3:1–10
23. Khairy GA, Kambal AM, Al-Dohayan AA, Al-Shehri MY,
Zubaidi AM, Al-Naami MY et al. Surgical site infection in a
teaching hospital: a prospective study. Journal of Taibah
University Medical Sciences 2011;6(2):114–120
AL-MULHIM PREVALANCE OF SSI IN ORTHOPEDIC SURGERY
268 Int Surg 2014;99
