Reported Practice Patterns Vary for the Management of Suspected Incisional Surgical Site Infection

Author(s):
Patrick Delaplain; Jeffrey Santos; Justin Dvorak; Tina Mele; Rondi Gelbard; Christopher Guidry; Philip Barie; Sebastian Schubl

Background:

Surveillance of surgical site infections (SSI) has become mandatory secondary to the associated morbidity, mortality, and cost. However, wound management and use of antibiotics (abx) vary widely among surgeons. There is little guidance, or even established consensus, regarding when empiric therapy for superficial SSIs should be initiated and what that therapy entails.

Hypothesis:

Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons.

Methods:

The Surgical Infection Society was surveyed regarding management of incisional SSI. Cases were provided with varying wound appearance, initial wound class, postoperative day (POD), and presence of a prosthesis. Responses were multiple choice format. Reported p-values are Chi-squared tests.

Results:

78 SIS members responded. Respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of abx, but purulence was more likely to be treated with abx than clear drainage (38% vs. 6%, p<0.001). There were no differences based on wound class, except that clean cases were more likely to be treated with gram + coverage alone (wound class 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%], p<0.001). POD 3 was an inflection point for more aggressive treatment, with fewer reporting observation alone (Table). Respondents were more likely to obtain imaging, start broad-spectrum abx, and return to the OR for purulent drainage in the presence of mesh.

Table. Responses for POD Scenarios*

	Count (%)			p-value
	POD 0	POD 3	POD 5
Observation	67(86)	42(54)	35(45)	<0.001
Abx (gram + only)	2(3)	8(10)	7(9)	0.14
Abx (gram – only)	1(1)	0(0)	0(0)	0.37
Broad-spectrum abx	5(6)	18(23)	21(27)	0.002
Imaging	1(1)	0(0)	6(8)	0.01
Partially open incision, wet-to-dry	1(1)	16(21)	25(32)	<0.001
Completely open incision, wet-to-dry	2(3)	2(3)	2(3)	1.0
Completely open incision, topical antiseptic	0(0)	1(1)	1(1)	0.6
Completely open incision, negative pressure wound therapy	3(4)	1(1)	2(3)	0.6
*Open adhesiolysis with enterotomy, minimal (<10 mL) spillage, primary repair, mild erythema.

Conclusions:

Presented with scenarios with escalating concern for SSI, respondents reported lower rates of observation, increased use of abx, and increased surgical drainage. However, many scenarios lack consensus regarding appropriate therapy (e.g., imaging, extent of incision opening, abx.)