1
Florida Heart CPR*
Wound Infection
1 hour
Introduction
History
The ancient Egyptians were the first civilization to have trained physicians to treat
physical aliments. Medical papyri, such as the Edwin Smith papyrus (circa 1600 BC)
and the Ebers papyrus (circa 1534 BC), provided detailed information of management
of disease, including wound management with the application of various potions and
grease to assist healing (Breasted, 1930; Bryan, 1930).
Hippocrates (Greek physician and surgeon, 460-377 BC), known as the father of
medicine, used vinegar to irrigate open wounds and wrapped dressings around wounds
to prevent further injury. His teachings remained unchallenged for centuries. Galen
(Roman gladiatorial surgeon, 130-200 AD) was first to recognize that pus from wounds
inflicted by the gladiators heralded healing (pus bonum et laudabile ["good and
commendable pus"]). Unfortunately, this observation was misinterpreted, and the
concept of pus preempting wound healing persevered well into the eighteenth century.
The link between pus formation and healing was emphasized so strongly that foreign
material was introduced into wounds to promote pus formation-suppuration. The
concept of wound healing remained a mystery, as highlighted by the famous saying by
Ambroise Par頨French military surgeon, 1510-1590), "I dressed the wound. God healed
it" (Cohen, 1998).
The scale of wound infections was most evident in times of war. During the American
Civil War, erysipelas (necrotizing infection of soft tissue) and tetanus accounted for over
17,000 deaths (anonymous, 1883). Because compound fractures at the time almost
invariably were associated with infection, amputation was the only option despite a 2590% risk of amputation stump infection.
Koch (Professor of Hygiene and Microbiology, Berlin, 1843-1910) first recognized the
cause of infective foci as secondary to microbial growth in his nineteenth century
postulates. Semmelweis (Austrian obstetrician, 1818-1865) demonstrated a 5-fold
reduction in puerperal sepsis by hand washing between performing postmortem
examinations and entering the delivery room. Joseph Lister (Professor of Surgery,
London, 1827-1912) and Louis Pasteur (French bacteriologist, 1822-1895)
revolutionized the entire concept of wound infection. Lister recognized that antisepsis
could prevent infection (Lister, 1867). In 1867, he placed carbolic acid into open
fractures to sterilize the wound and prevent sepsis and hence the need for amputation.
In 1871, Lister began to use carbolic spray in the operating room to reduce
contamination. However, the concept of wound suppuration persevered even among
eminent surgeons, such as John Hunter, 1728-1793, (Qvist, 1979).
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Wound Infection
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World War I (WWI) resulted in new types of wounds from high-velocity bullet and
shrapnel injuries coupled with contamination by the mud from the trenches. Antoine
Depage (Belgian military surgeon, 1862-1925) reintroduced wound debridement and
delayed wound closure and relied on microbiological assessment of wound brushings
as guidance for the timing of secondary wound closure (Helling, 1998). Alexander
Fleming (microbiologist, London, 1881-1955) performed many of his bacteriological
studies during WWI and is credited with the discovery of penicillin.
As late as the nineteenth century, aseptic surgery was not routine practice. Sterilization
of instruments began in the 1880s as did the wearing of gowns, masks, and gloves.
Halsted (Professor of Surgery, Johns Hopkins University, United States, 1852-1922)
introduced rubber gloves to his scrub nurse (and future wife) because she was
developing skin irritation from the chemicals used to disinfect instruments. The routine
use of gloves was introduces by Halsted?s student J. Bloodgood.
Penicillin first was used clinically in 1940 by Howard Floery. With the use of antibiotics,
a new era in the management of wound infections commenced. Unfortunately,
eradication of the infective plague affecting surgical wounds has not ended because of
the insurgence of antibiotic-resistant bacterial strains and the nature of more
adventurous surgical intervention in immunocompromised patients and in implant
surgery.
Pathophysiology: Wound healing is a continuum of complex interrelated biological
processes at the molecular level. Healing is divided into the following phases for
descriptive purposes: inflammatory phase, proliferative phase, and maturation phase.
The inflammatory phase commences as soon as tissue integrity is disrupted by injury;
this begins the coagulation cascade to limit bleeding. Platelets are the first of the cellular
components that aggregate to the wound, and, as a result of their degranulation
(platelet reaction), they release several cytokines (or paracrine growth factors). These
cytokines include platelet derived growth factor (PDGF), insulinlike growth factor-1 (IGF1), epidermal growth factor (EGF), and fibroblast growth factor (FGF) (Bennett, 1993).
Serotonin is also released, which, together with histamine (released by mast cells),
induces a reversible opening of the junctions between the endothelial cells, allowing the
passage of neutrophils and monocytes (which become macrophages) to the site of
injury.
This large cellular movement to the injury site is induced by cytokines secreted by the
platelets (chemotaxis) and by further chemotactic cytokines secreted by the
macrophages themselves once at the site of injury. These include transforming growth
factor alpha (TGF-alpha) and transforming growth factor beta (TGF-beta).
Consequently, an inflammatory exudate that contains red blood cells, neutrophils,
macrophages, and plasma proteins, including coagulation cascade proteins and fibrin
strands, fills the wound in a matter of hours. Macrophages not only scavenge but they
also are central to the wound healing process because of their cytokine secretion.
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Wound Infection
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The proliferative phase begins as the cells that migrate to the site of injury, such as
fibroblasts, epithelial cells, and vascular endothelial cells, start to proliferate and the
cellularity of the wound increases. The cytokines involved in this phase include FGFs,
particularly FGF-2 (previously known as basic FGF), which stimulates angiogenesis and
epithelial cell and fibroblast proliferation (Fernig, 1994). The marginal basal cells at the
edge of the wound migrate across the wound, and, within 48 hours, the entire wound is
epithelialized. In the depth of the wound, the number of inflammatory cells decreases
with the increase in stromal cells, such as fibroblasts and endothelial cells, which in turn
continue to secrete cytokines. Cellular proliferation continues with the formation of
extracellular matrix proteins, including collagen and new capillaries (angiogenesis). This
process is variable in length and may last several weeks.
In the maturation phase, the dominant feature is collagen. The dense bundle of fibers,
characteristic of collagen, is the predominant constituent of the scar. Wound contraction
occurs to some degree in primary closed wounds but is a pronounced feature in wounds
left to close by secondary intention. The cells responsible for wound contraction are
called myofibroblasts, which resemble fibroblasts but have cytoplasmic actin filaments
responsible for contraction.
The wound continuously undergoes remodeling to try to achieve a state similar to that
prior to injury. The wound has 70-80% of its original tensile strength at 3-4 months
postoperative.
Frequency:


In the US: Surgical site infections (SSIs) are not an extinct entity; they account
for 14-16% of the estimated 2 million nosocomial infections affecting hospitalized
patients in the United States (Emori, 1993).
Internationally: Internationally, the frequency of SSI is difficult to monitor
because criteria for diagnosis might not be standardized. A survey sponsored by
the World Health Organization demonstrated a prevalence of nosocomial
infections varying from 3-21%, with wound infections accounting for 5-34% of the
total (Mayon-White, 1988).
Collated data on the incidence of wound infections probably underestimate true
incidence because most wound infections occur when the patient is discharged,
and these infections may be treated in the community without hospital
notification.
Mortality/Morbidity: SSIs are associated not only with increased morbidity but also
with mortality. Seventy-seven percent of the deaths of surgical patients were related to
surgical wound infection (Mangram, 1999). Kirkland et al (1999) calculated a relative
risk of death of 2.2 attributable to SSIs, compared to matched surgical patients without
infection.
Clinical
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Wound Infection
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History: SSI is a difficult term to define accurately because it has a wide spectrum of
possible clinical features. The Centers for Disease Control and Prevention (CDC) have
defined SSI to standardize data collection for the National Nosocomial Infections
Surveillance (NNIS) program (CDC, 1996). SSIs are classified into incisional SSIs,
which can be superficial or deep, or organ/space SSIs, which affect the rest of the body
other than the body wall layers.

Definitions of SSI
o
o
o
Superficial incisional SSI: Infection involves only skin and subcutaneous
tissue of incision.
Deep incisional SSI: Infection involves deep tissues, such as fascial and
muscle layers. This also includes infection involving both superficial and
deep incision sites and organ/space SSI draining through incision.
Organ/space SSI: Infection involves any part of the anatomy in organs and
spaces other than the incision, which was opened or manipulated during
operation.
Physical:
 Criteria for defining an SSI
o Infection occurs 30 days after operation.
o If an implant is left in place, SSI occurs 1 year postoperatively if related to
surgery and at least 1 of the following is present:







Purulent discharge from surgical site
At least 1 of the signs and symptoms of infection?pain or
tenderness, localized swelling, redness, or heat
Spontaneous dehiscence of wound or deliberate opening of wound
by surgeon unless site is culture results are negative
Purulent discharge from wound or drain placed in wound
Abscess or evidence of infection on direct examination or
reoperation or histopathologic or radiologic examination
Diagnosis of infection by a surgeon or attending physician
Exclusion criteria
o Stitch abscess (minimal inflammation/discharge confined to the points of
suture penetration)
o Episiotomy infections or newborn circumcision scars
o Infected burn wound
Causes: The establishment of a wound infection requires a microbial inoculum of the
surgical site in a susceptible host. Factors affecting wound infection include
preoperative removal of hair, especially with instruments capable of causing skin
abrasion, inadequate skin preparation with bactericidal solution, host who is
immunocompromised, and delayed prophylaxis with antibiotics or incorrect choice of
antibiotics.
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

Microbiology
o
The traditional microbial concentration quoted as being highly associated
with SSIs is that of bacterial counts higher than 10,000 organisms per
gram of tissue (or in the case of burned sites, organisms per cm2 of
wound) (Krizek, 1975). The infective process not only depends on the
number of contaminating microbes but also on their virulence and whether
the resistance offered by the host patient is strong enough to fight off the
invading organisms.
o
Most SSIs are contaminated by the patient's own endogenous flora, which
are present on the skin, mucous membranes, or hollow viscera. The usual
pathogens on skin and mucosal surfaces are gram-positive cocci (notably
staphylococci); however, gram-negative aerobes and anaerobic bacteria
contaminate skin in the groin/perineal areas. The contaminating
pathogens in gastrointestinal surgery are the multitude of intrinsic bowel
flora, which include gram-negative bacilli (eg, Escherichia coli) and grampositive microbes, including enterococci and anaerobic organisms. See
Table 1 for pathogens and their frequencies. Gram-positive organisms,
particularly staphylococci and streptococci, account for the vast majority of
exogenous flora involved in SSIs. Sources of such pathogens include
surgical/hospital personnel and intraoperative circumstances, including
surgical instruments, articles brought into the operative field, and the
operating room air.
Risk factors (other than microbiology)
o
Decreased host resistance can be due to systemic factors affecting the
patient's healing response, local wound characteristics, or operative
characteristics.
 Systemic factors include age, malnutrition, hypovolemia, poor
tissue perfusion, obesity, diabetes, steroids, and other
immunosuppressants.
 Wound characteristics include nonviable tissue in wound;
hematoma; foreign material, including drains and sutures; dead
space; poor skin preparation, including shaving; and preexistent
sepsis (local or distant).
 Operative characteristics include poor surgical technique; lengthy
operation (>2 h); intraoperative contamination, including infected
theater staff and instruments and inadequate theater ventilation;
prolonged preoperative stay in the hospital; and hypothermia.
o
The type of procedure is a risk factor. Certain procedures are associated
with a higher risk of wound contamination than others. Surgical wounds
have been classified as clean, clean-contaminated, contaminated, and
dirty-infected (see Table 2).
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Wound Infection
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Workup
Lab Studies:

Staining methods: The simplest, and usually the quickest, method involves
obtaining a Gram stain for infective organisms. Staining for fungal elements can
be obtained at the same time.

Culture techniques: Most laboratories routinely will culture for both aerobic and
anaerobic organisms. Fungal cultures can be requested. Isolation of single
colonies allows further growth and identification of the specific organism.
Sensitivity testing then follows mainly for aerobic organisms.

Newer techniques
o
o
o
o
Tests for antigens from the organism through enzyme-linked
immunoassay (ELISA) or radioimmunoassay
Detection of antibody response to the organism in the host sera
Detection of RNA or DNA sequences or protein from the infective
organism by Northern, Southern, or Western blotting, respectively
Polymerase chain reaction (PCR) is a sensitive assay to detect small
amounts of microbe DNA.
Imaging Studies:

Ultrasound can be applied to the infected wound area to assess whether any
collection needs drainage.
Treatment
Medical Care: The use of antibiotics was a milestone in the effort to prevent wound
infection. The concept of prophylactic antibiotics was established in the 1960s when
experimental data established that antibiotics had to be in the circulatory system at a
high enough dose at the time of incision to be effective (Burke, 1961).
General agreement exists that prophylactic antibiotics are indicated for cleancontaminated and contaminated wounds (see Table 2). Antibiotics for dirty wounds are
part of the treatment because infection is established already. Clean procedures might
be an issue of debate. No doubt exists regarding the use of prophylactic antibiotics in
clean procedures in which prosthetic devices are inserted because infection in these
cases would be disastrous for the patient. However, other clean procedures (eg, breast
surgery) may be a matter of contention (Gupta, 2000; Platt, 1993).
Qualities of prophylactic antibiotics include efficacy against predicted bacterial
microorganisms most likely to cause infection, good tissue penetration to reach wound
involved, cost effectiveness, and minimal disturbance to intrinsic body flora (eg, gut).
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Wound Infection
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The timing of administration is critically important because the concentration of the
antibiotic should be at therapeutic levels at the time of incision, during the surgical
procedure, and, ideally, for a few hours postoperatively (CDC, 1996). Administration of
the antibiotic is by IV; 30 minutes prior to incision is the recommended time (Woods,
1998). Antibiotics should not be administered more than 2 hours prior to surgery.
Colorectal surgical prophylaxis additionally requires bowel clearance with enemas and
oral nonabsorbable antimicrobial agents 1 hour before surgery. High-risk cesarean
surgical cases require antibiotic administration as soon as the clamping of the umbilical
cord is completed (CDC, 1996). See Table 3 for specific antibiotics recommended.
The current risk index used to predict the risk of developing a wound infection is the
NNIS system of the CDC (CDC, 1996). The risk index category is established by the
added total of the risk factors present at the time of surgery. For each risk factor
present, a point is allocated; risk index values range from 0-3. This risk index is a better
predictor for SSIs than the surgical wound classification (see Table 2 and Table 5)
(Culver, 1991). The elements that constitute the NNIS risk index are as follows:




Preoperative patient physical status assessed by the anesthesiologist and
classified by the American Society of Anesthesiologists (see Table 4) as greater
than 3
Operation status as either contaminated or dirty-infected (see Table 2)
Operation lasting longer than T hours, where T is the 75th percentile of the
specific operation performed
Hospital Infection Control Practices Advisory Committee (HICPAC)
Recommendations (partial) for the prevention of SSIs, April 1999, (non?drug
based)
Preoperative circumstances
Patient preparation

Category IA criteria
o
o

Identify and treat all infections remote from the surgical site. Delay
operation in elective cases until infection is treated.
Do not remove hair unless it infringes on the surgical field. If hair removal
is required, it should be removed immediately before operation and
preferably with electric clippers.
Category IB criteria
o
o
Patients should cease tobacco consumption in any form for at least 1
month preoperatively.
Optimize blood glucose level and avoid hyperglycemia.
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o
o


Patients are to shower/bathe with antiseptic on at least the night before
surgery.
Necessary blood products may be administered.
Category II criteria: Provided preoperative patient preparation is adequate,
minimize preoperative hospital stay.
No recommendation
o Gradual reduction/discontinuation steroid use before elective surgery
o Enhanced nutritional intake solely to prevent SSI
o Preoperative topical antibiotic use in nares to prevent SSI
o Measures to enhance wound space oxygenation
Surgical team members
 Category IB
o
o
o
o
o
o
o
o
o
o
o
o

Keep fingernails short; do not wear artificial nails.
Scrub hands and forearms as high as the elbows for at least 2-5 minutes
with appropriate antiseptic.
After scrub, keep hands up with elbows flexed and away from the body;
use a sterile towel to dry the hands and put on a sterile gown and gloves.
Masks should be worn in the operating suite if sterile instruments are
exposed and throughout the surgical procedure. Masks should cover the
mouth and nose.
The hair on the head and face is to be covered with a hood or cap.
Liquid-resistant sterile surgical gowns and sterile gloves are to be worn by
scrubbed surgical team members.
Visibly soiled gowns are to be changed.
Shoe covers are not necessary.
Routine exclusion of personnel colonized by organisms such as
Staphylococcus aureus or group A streptococci is not necessary unless
they are specifically linked to dissemination of such organisms.
Personnel with skin lesions that are draining are to be excluded from duty
until treated and the infection has resolved.
Educate and encourage surgical personnel regarding reporting illness of
transmissible nature to supervisory and occupational health personnel.
Policies should be established concerning patient care responsibilities for
personnel with potentially transmissible infective illnesses. This should
include aspects of work restrictions, personnel responsibility in utilizing
health services, and declaring illness. Policies also should direct the
responsible person to remove personnel from duty, and policy should be
established for clearance to resume work.
Category II
o
Clean the under fingernails prior to the first scrub of the day.
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Do not wear arm/hand jewelry.
No recommendation
o Nail polish
o Restriction of scrub suits to the operating theater
o Covering the scrub suits when outside the theater
o How or where to launder theater suites
o

Preoperative and postoperative wound care



Category IA: Asepsis is necessary in the insertion of indwelling catheters, such
as intravascular, spinal, or epidural catheters, and subsequent infusion of drugs.
Category IB
o Handle tissues gently with good hemostasis, minimize foreign bodies, and
minimize devitalized tissue and dead space.
o For Class III and IV wounds use delayed closure or leave the wound
incision open to heal by secondary intention.
o If draining of a wound is necessary, the drain exit should be via separate
incision distant from the wound. Remove the drain as soon as possible.
o Primary closed incisions should be protected with a sterile dressing for 2448 hours.
o Hands are to be washed before and after wound dressing changes/or
contact.
Category II
o Use sterile technique for wound dressing change.
o Educate the patient and relatives regarding wound care symptoms of SSIs
and the need to report such problems.
Theater environment and care of instrumentation
 Category IB
o Maintain positive pressure ventilation of the operating suite relative to
corridors and surrounding areas.
o Maintain a minimum of 15 air changes per hour, with a minimum of 3
being fresh air.
o Appropriate filters (as recommended by the American Institute of
Architects) should be used for filtration of all air whether recirculated or
fresh.
o Air should enter through the ceiling and exit near the floor.
o Keep operating room doors closed except for necessary entry.
o The use of ultraviolet lamps in the theater is not necessary as a deterrent
of SSI.
o Prior to subsequent procedures, visibly soiled surfaces should be cleaned
with Environmental Protection Agency (EPA)?approved disinfectants.
o Following a contaminated or dirty procedure, special cleaning or closure of
the operating suite is not necessary.
o Use of tacky mats prior to entry in the operating suite is not necessary.
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Wound Infection
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o
o
Sterile surgical instruments and solutes should be assembled just prior to
use.
All surgical instruments should be sterilized according to guidelines. Flush
sterilization should only be used for instruments that are required for
immediate patient use.

Category II
o Limit the number of personnel entering the operating suite.
o Orthopedic implant surgery should be performed in an ultra clean air
environment.
o Wet vacuum the floor of the operating theater at the end of day/night using
an EPA-approved disinfectant.
Special situations

Elective colon surgery: Bowel surgery results in the breakdown of the protective
intestinal mucous membrane, with release of the facultative and anaerobic
bacteria that heavily colonize the distal small bowel and colon. Eradication of
aerobes and anaerobes is necessary to reduce infective complications following
intestinal procedures. Mechanical cleansing and antibiotics could achieve this.
Mechanical cleansing for colonic surgery can take the form of dietary restrictions;
whole gut lavage with one of several preparations, such as 10% mannitol
solution, Fleet?s phospho-soda, or polyethylene glycol, usually is performed on
the day of surgical intervention. Enteral antibiotic regimes to eradicate intrinsic
bowel flora vary, with oral neomycin and erythromycin being the most popular
combination used in the United States. Other combinations with neomycin
include the use of metronidazole and tetracycline. Prophylactic parenteral
antibiotics also are used with the above as recommended in Table 3.

Intravascular device-related infections: Intravascular devices are of vital use in
daily hospital practice. Their use is for the parenteral administration of fluids,
blood products, nutrition fluids, medication, and access to hemodialysis; equally
important is their use in the monitoring of critically ill patients. Unfortunately,
because their use constitutes an invasive procedure, they are associated with
infectious complications that could be of a local or systemic nature.
Recommendations for prevention (Pearson, 1995) and treatment (Mermel, 2001)
are available to limit their associated morbidity and mortality (which could be as
high as 20% in patients with catheter-related bloodstream infections).
Surgical Care: Although the goal of every surgeon is to prevent wound infections, they
will arise. Treatment is individualized to the patient, the wound, and the nature of the
infection. The operating surgeon should be made aware of the possibility of infection in
the wound and determine the treatment for the wound.
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Wound Infection
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Such treatment often involves opening the wound, evacuating pus, and cleansing the
wound. The deeper tissues are inspected for integrity and for a deep space infection or
source. Dressing changes allow the tissues to granulate, and the wound heals by
secondary intention over several weeks.
The choice of antibiotic depends on 2 factors?the patient and the known or probable
infecting microorganism. Patient factors include allergies, hepatic and renal function,
severity of disease process, interaction with other medication(s), and age. In women,
pregnancy and breastfeeding must be considered.
Drug Category: Antibiotics -- Therapy must be comprehensive and cover all likely
pathogens in the context of this clinical setting.
Follow-Up
Further Inpatient Care:

Resultant increased hospital stay due to SSI has been estimated at 7-10 days,
increasing hospitalization costs by 20% (Haley, 1981).
 Occasionally, further intervention in the form of wound debridement and
subsequent packing and frequent dressing is necessary to allow healing by
secondary intention.
Further Outpatient Care:

Most patients with wound infections are managed in the community.
Management usually takes the form of dressing changes to optimize healing,
which usually is by secondary intention.
Medical/Legal Pitfalls:



Always inquire about whether the patient has any medication allergies before
prescribing antibiotics.
Failure to prescribe prophylactic antibiotics for a procedure as recommended
above may result in the surgeon being held accountable if the patient has
increased morbidity or mortality from the surgical procedure.
A medicolegal issue may arise for failure to recognize an infected prosthesis and
institute prompt action.
REFERENCES:

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Anesthesiology: New classification of physical status. Anesthesiology 1963; 24:
111.
Breasted D: The Edwin Smith Surgical Papyrus. University of Chicago: University
of Chicago press; 1930.
Bryan PW: The Papyrus Ebers. London/Washington DC: Government Printing
Office; 1883.
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Burke JF: The effective period of preventive antibiotic action in experimental
incisions and dermal lesions. Surgery 1961; 50: 161-168.
Cohen IK: A brief history of wound healing. 1st ed. Yardley, Pa: Oxford Clinical
Communications Inc; 1998.
Cruse PJ, Foord R: The epidemiology of wound infection. A 10-year prospective
study of 62,939 wounds. Surg Clin North Am 1980 Feb; 60(1): 27-40
Culver DH, Horan TC, Gaynes RP: Surgical wound infection rates by wound
class, operative procedure, and patient risk index. National Nosocomial
Infections Surveillance System. Am J Med 1991 Sep 16; 91(3B): 152S-157S
Emori TG, Gaynes RP: An overview of nosocomial infections, including the role
of the microbiology laboratory. Clin Microbiol Rev 1993 Oct; 6(4): 428-42
Gupta R, Sinnett D, Carpenter R: Antibiotic prophylaxis for post-operative wound
infection in clean elective breast surgery. Eur J Surg Oncol 2000 Jun; 26(4): 3636
Haley RW, Schaberg DR, Crossley KB: Extra charges and prolongation of stay
attributable to nosocomial infections: a prospective interhospital comparison. Am
J Med 1981 Jan; 70(1): 51-8
Helling TS, Daon E: In Flanders fields: the Great War, Antoine Depage, and the
resurgence of debridement. Ann Surg 1998 Aug; 228(2): 173-81
Kirkland KB, Briggs JP, Trivette SL: The impact of surgical-site infections in the
1990s: attributable mortality, excess length of hospitalization, and extra costs.
Infect Control Hosp Epidemiol 1999 Nov; 20(11): 725-30
Krizek TJ, Robson MC: Evolution of quantitative bacteriology in wound
management. Am J Surg 1975 Nov; 130(5): 579-84
Lister J: On a new method of treating compound fractures. Lancet 1867; 1: 326329,387-389,507-509.
Mangram AJ, Horan TC, Pearson ML: Guideline for prevention of surgical site
infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect
Control Hosp Epidemiol 1999 Apr; 20(4): 250-78; quiz 279-80
Mayon-White RT, Ducel G, Kereselidze T: An international survey of the
prevalence of hospital-acquired infection. J Hosp Infect 1988 Feb; 11 Suppl A:
43-8
Mermel LA, Farr BM, Sherertz RJ: Guidelines for the management of
intravascular catheter-related infections. Clin Infect Dis 2001 May 1; 32(9): 124972
NNIS System: National Nosocomial Infections Surveillance (NNIS) report, data
summary from October 1986-April 1996, issued May 1996. A report from the
National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control
1996 Oct; 24(5): 380-8
Pearson ML: Guideline for prevention of intravascular device-related infections.
Part I. Intravascular device-related infections: an overview. The Hospital Infection
Control Practices Advisory Committee. Am J Infect Control 1996 Aug; 24(4): 26277
Platt R, Zucker JR, Zaleznik DF: Perioperative antibiotic prophylaxis and wound
infection following breast surgery. J Antimicrob Chemother 1993 Feb; 31 Suppl
B: 43-8
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Qvist G: Hunterian Oration, 1979. Some controversial aspects of John Hunter's
life and work. Ann R Coll Surg Engl 1979 Jul; 61(4): 309-11
Florida Heart CPR*
Wound Infection Assessment
1. Sterilization of instruments began in the 1880s as did the wearing of
a. Gowns
b. Masks
c. Gloves
d. All of the above
2. The _______ commences as soon as tissue integrity is disrupted by injury; this
begins the coagulation cascade to limit bleeding.
a. Reconstructive phase
b. Regenerative phase
c. Inflammatory phase
d. Maturation phase
3. The _________begins as the cells that migrate to the site of injury, such as
fibroblasts, epithelial cells, and vascular endothelial cells, start to proliferate and
the cellularity of the wound increases.
a. Inflammatory phase
b. Maturation phase
c. Proliferative phase
d. Regenerative phase
4. In the _________the dominant feature is collagen. The dense bundle of fibers,
characteristic of collagen, is the predominant constituent of the scar. Wound
contraction occurs to some degree in primary closed wounds but is a pronounced
feature in wounds left to close by secondary intention.
a. Regenerative phase
b. Proliferative phase
c. Inflammatory phase
d. Maturation phase
5. Most surgical site infections are contaminated by _______, which are present on
the skin, mucous membranes, or hollow viscera.
a. Bacteria on the surgical equipment
b. Germs transferred to the patient from the medical staff
c. The patient’s own endogenous flora
d. Unknown origin
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6. The concept of prophylactic antibiotics was established in the 1960s when
experimental data established that antibiotics had to be in the circulatory system
at a high enough dose __________ to be effective.
a. 24 hours before the surgery
b. By the time the surgery is over
c. At the time of incision
d. By the second day of recovery
7. Qualities of prophylactic antibiotics include efficacy against predicted bacterial
microorganisms most likely to cause infection and:
a. Cost effectiveness
b. Minimal disturbance to intrinsic body flora
c. Good tissue penetration to reach the wound involved
d. All of the above
8. Resultant increased hospital stay due to SSI has been estimated at ____,
increasing hospitalization costs by 20%
a. 7-10 days
b. 1-2 weeks
c. 3-4 days
d. 10-15 days
9. Most patients with wound infections are managed _______. Management usually
takes the form of dressing changes to optimize healing, which usually is by
secondary intention.
a. In the community
b. In the hospital
c. In the operating room
d. In hospice centers
10. Always inquire about whether the patient has any ______ before prescribing
antibiotics.
a. Food allergies
b. Respiratory allergies
c. Medication allergies
d. Pet allergies
Florida Heart CPR*
Wound Infection