ACCURACY OF SURGICAL WOUND INFECTION DEFINITIONS-THE FIRST STEP TOWARDS SURVEILLANCE OF SURGICAL SITE INFECTIONS

Abstract

REZUMAT ACCURACY OF SURGICAL WOUND INFECTION DEFINITIONS THE FIRST STEP TOWARDS SURVEILLANCE OF SURGICAL SITE INFECTIONS Alina Petrica1, Cristina Brinzeu2, Antoniu Brinzeu2, Razvan Petrica3, Mihai Ionac4 An ideal surveillance system should have several attributes: meaningful definitions of infection, consistent interpretation of classification criteria, applicability to procedures performed in both inpatient and ambulatory facilities, ability to detect events after discharge, sufficient precision to distinguish small absolute differences in attack rates, and reasonable cost.5-7 In 2001, Bruce et al made a comprehensive review of the literature in searching for evidence for the validity and reliability of definitions of wound infection.8 Authors searched the MEDLINE, CINAHL, EMBASE, Cochrane Library, and HealthSTAR databases from 1993 to 1999 and strict inclusion and exclusion criteria were applied to studies retrieved for appraisal. Of 2,490 abstracts identified to assess the definition of surgical wound infection, 90 prospective studies from 20 countries were included in the analysis. Forty-one different definitions of surgical wound or SSI were identified; some were “standard” definitions used by national surveillance programmes: the Public Health Laboratory Service (NPS), the Surgical Infection Society Study Group, the Second UK National Prevalence Survey, and the Centers for Disease Control (CDC) 1988 and 1992 definitions. There was no single symptom common to all definitions, but the most common criteria of infection was purulent discharge. Received for publication: Sep. 11, 2009. Revised: Dec. 08, 2009. _____________________________ Alina Petrica et al 363 DEFINITIONS The most widely recognized definition of infection, used throughout the USA and Europe, is that devised by Horan and colleagues and adopted by the CDC.9 According to CDC definition, surgical site infections are classified into three groups – superficial, deep incisional SSIs and organ-space SSIs – depending on the site and the extent of infection. These definitions are summarized in Table 1. ASEPSIS is an acronym of seven wound assessment parameters. (Table 2) It’s a quantitative scoring method that provides a numerical score related to the severity of wound infection using objective criteria based on wound appearance and the clinical consequences of the infection.10,11 Table 1. CDC definitions of surgical site infections. The ASEPSIS system was ment to assess wounds resulting from cardiothoracic surgery, while the Southampton scale was designed for use in the postoperative assessment of hernia wounds. The Southampton system is much simpler than the ASEPSIS system, with wounds being categorized according to any complications and their extent.12 Both systems, however, have been developed for use following specific types of surgery and this may limit their usefulness.1 Southampton scale by using the worst wound score recorded and information about any treatment instituted either in hospital or the community, wounds were regarded in four categories: (Table 3) a. normal healing; b. minor complication; Table 1. CDC definitions of surgical site infections Superficial incisional surgical site infections Superficial incisional surgical site infections must meet the following two criteria2:  occur within 30 days of procedure  involve only the skin or subcutaneous tissue around the incision. Plus At least one of the following criteria:  purulent drainage from the incision  organisms isolated from an aseptically obtained culture of fluid or tissue from the incision  at least one of the following signs or symptoms of infection – pain or tenderness, localized swelling, redness or heat – and the incision is deliberately opened by a surgeon, unless the culture is negative  diagnosis of superficial incisional SSI by a surgeon or attending physician. The following are not considered superficial SSIs:  stitch abscesses (minimal inflammation and discharge confined to the points of suture penetration)  infection of an episiotomy or neonatal circumcision site  infected burn wounds  incisional SSIs that extend into the fascial and muscle layers (see deep SSIs). Deep incisional surgical site infections Deep incisional surgical site infections must meet the following three criteria2:  occur within 30 days of procedure (or one year in the case of implants)  are related to the procedure  involve deep soft tissues, such as the fascia and muscles. Plus At least one of the following criteria:  purulent drainage from the incision but not from the organ/space of the surgical site  a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of following signs or symptoms – fever (>38°C), localized pain or tenderness – unless the culture is negative  an abscess or other evidence of infection involving the incision is found on direct examination or by histopathologic or radiological examination  diagnosis of a deep incisional SSI by a surgeon or attending physician. An organ/space SSI An organ/space SSI must meet the following criterion: Infection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and patient has at least 1 of the following: a. purulent drainage from a drain that is placed through a stab wound into the organ/space b. organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space c. an abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination d. diagnosis of an organ/space SSI by a surgeon or attending physician.