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Original Article
Rev. Latino-Am. Enfermagem
2011 Nov.-Dec.;19(6):1362-8
www.eerp.usp.br/rlae
Risk of surgical site infection in patients undergoing
orthopedic surgery
Flávia Falci Ercole1
Lúcia Maciel Castro Franco2
Tamara Gonçalves Rezende Macieira3
Luísa Cristina Crespo Wenceslau3
Helena Isabel Nascimento de Resende3
Tânia Couto Machado Chianca4
This study aimed to identify risk factors associated with surgical site infections in orthopedic
surgical patients at a public hospital in Minas Gerais, Brazil, between 2005 and 2007. A historical
cohort of 3,543 patients submitted to orthopedic surgical procedures. A descriptive analysis was
conducted and surgical site infection incidence rates were estimated. To verify the association
between infection and risk factors, the Chi-square Test was used. The strength of association
of the event with the independent variables was estimated using Relative Risk, with a 95%
confidence interval and p<0.05. The incidence of surgical site infection was 1.8%. Potential
surgical wound contamination, clinical conditions, time and type of surgical procedure were
statistically associated with infection. Identifying the association between surgical site infection
and these risk factors is important and contributes to nurses’ clinical practice.
Descriptors: Surgical Wound Infection; Risk Factors; Nursing; Orthopedics.
1
RN, Ph.D. in Sciences, Adjunct Professor, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. E-mail:
2
RN, Master’s Student in Nursing, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. Hospital Governador
3
Undergraduate students in Nursing, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. E-mail: Tamara
4
RN, Ph.D. in Nursing, Associate Professor, Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil. E-mail:
flavia.ercole@gmail.com.
Israel Pinheiro, Instituto de Previdência dos Servidores de Minas Gerais, Belo Horizonte, MG, Brazil. E-mail: luciamcf@terra.com.br.
– tata-macieira@hotmail.com, Luísa - luisawenceslau@gmail.com, Helena – helenainr@gmail.com.
taniachianca@gmail.com.
Corresponding Author:
Flávia Falci Ercole
Universidade Federal de Minas Gerais. Escola de Enfermagem
Av. Prof. Alfredo Balena, 190, Sala 220
Bairro: Santa Efigênia
CEP: 30130-100, Belo Horizonte, MG, Brasil
E-mail: flavia.ercole@gmail.com
1363
Risco para infecção de sítio cirúrgico em pacientes submetidos a
cirurgias ortopédicas
Objetivou-se, neste estudo, identificar fatores de risco associados às infecções de sítio
cirúrgico, em pacientes cirúrgicos ortopédicos, de um hospital público de Minas Gerais,
Brasil, entre 2005 e 2007. Como método usou-se coorte histórica em 3.543 pacientes
submetidos a cirurgias ortopédicas. Análise descritiva e taxa de incidência de infecção
foram estimadas. Para verificar a associação entre a infecção e os fatores de risco usouse o teste qui-quadrado. A força da associação do evento com as variáveis independentes
foi estimada pelo risco relativo, intervalo de confiança de 95% e p<0,05. A incidência
de infecção de sítio cirúrgico foi de 1,8%. Potencial de contaminação da ferida cirúrgica,
condições clínicas do paciente, tempo cirúrgico e tipo de procedimento ortopédico foram
estatisticamente associados à infecção. A identificação de associação de infecção de sítio
cirúrgico aos fatores de risco mencionados é importante e contribui para a prática clínica
do enfermeiro.
Descritores: Infecção da Ferida Operatória; Fatores de Risco; Enfermagem; Ortopedia.
Riesgo para infección de sitio quirúrgico en pacientes sometidos a
cirugías ortopédicas
Estudio para identificar factores de riesgo asociados a infecciones de sitio quirúrgico en
pacientes quirúrgicos ortopédicos de un hospital público de Minas Gerais, Brasil, entre
2005 y 2007. Cohorte histórica de 3.543 pacientes sometidos a cirugías ortopédicas.
Un análisis descriptivo fue realizado y la tasa de incidencia de infección fue estimada.
Para verificar la asociación entre la infección y los factores de riesgo se usó el test chicuadrado. La fuerza de la asociación del evento con las variables independientes fue
estimada por el Riesgo Relativo, con un intervalo de confianza de 95% y p <0,05. La
incidencia de infección de sitio quirúrgico fue 1,8%. Fueron estadísticamente asociados a
la infección el potencial de contaminación de la herida quirúrgica, las condiciones clínicas
del paciente, el tiempo quirúrgico y el tipo de procedimiento ortopédico. La identificación
de asociación de infección de sitio quirúrgico con los factores de riesgo mencionados es
importante y contribuye para la práctica clínica del enfermero.
Descriptores: Infección de Herida Operatoria; Factores de Riesgo; Enfermería; Ortopedia.
Introduction
are
considered severe. During these surgeries, in general,
considered severe complications and represent a serious
Healthcare-associated
infections
(HAI)
implantation materials are used, which increases the
threat to hospitalized patients’ safety
. They increase
risk of infection, a complication that can bring about the
morbidity-mortality rates, hospitalization costs due to
loss of the operated limb and even death(3,6). In Brazil,
the extended hospital stay and spending on diagnostic
SSI ranks third among all healthcare infections and is
and therapeutic procedures, besides neglecting patient’s
responsible for 14% to 16% of infections in hospitalized
distancing from their work and family
patients, with an 11% incidence rate(7). Some Brazilian
(1-2)
.
(3-4)
Among the main HAI sites, surgical site infection
studies evidenced orthopedic SSI rates ranging between
(SSI) can derive from a surgical act. It is defined as
1.4 and 40.3%(8-9).
any infection involving tissue, the incised organ and
Extrinsic
and
intrinsic
risk
factors
associated
the cavity manipulated during a surgical procedure .
with orthopedic infection include the patient’s clinical
Among SSIs, those related to orthopedic procedures are
conditions, prolonged preoperative hospitalization time,
(5)
www.eerp.usp.br/rlae
1364
Rev. Latino-Am. Enfermagem 2011 Nov.-Dec.;19(6):1362-8.
surgery length, skin preparation, surgeon and team’s
Centers for Disease Control and Prevention’s (CDC-
hand degerming technique, environmental conditions
Atlanta) National Nosocomial Infections Surveillance
of operating room, number of people inside the room,
System-NNISS,
surgeon’s technique and skills, use of implants, among
discharge happen on different calendar days, with a sole
others(8-12).
operating room entry and where the surgeon made at
To
control
surgical
infections
and
as
patients
whose
admission
and
establish
least one skin or mucous membrane incision, including
prevention measures, infection risk factors need to be
laparoscopic methods, besides closing the incision
identified, which are normally related with the host,
before the patient leaves the operating room(5).
microorganism, environment and type of implanted
Surgical site infection was analyzed in orthopedic
material. Knowing these factors is important for nursing
surgical procedures, as well as their possible risk factors.
action planning and practice, such as environmental
SSI categorization was based on the absence and
control,
presence of infection, and can be superficial incisional,
bathing,
perioperative
infection
control,
medication control and incision site care(2,8,11,13).
deep incisional and organ space(5). Risk factors for
More solid evidence-based research is required to
SSI were considered as independent variables, i.e.
identify risk factors related to surgical site infection, as
those variables whose presence is associated with a
these can directly influence nursing practice, considering
greater probability than an infection will develop(5,11):
that a surgical wound increased infection risks due to
gender; NNIS Surgical Infection Risk Index (scores 0,
the ruptured skin barrier, handling of organs and spaces
1, 2 and 3); surgical wound contamination potential
and presence of implantable devices. Preventing the
(clean, potentially contaminated, contaminated and
problem based on the monitoring of risk factors and
infected); general anesthesia (no and yes); patients’
putting in practice actions to minimize SSI should be
preoperative clinical conditions, analyzed using ASA
taken into account.
I,II,III,IV and V, the criterion proposed by the American
In view of the above, and considering that nurses
Society
of
Anesthesiologists(5,13,15);
emergency
(no
identify most situations representing SSI risks, this study
and yes); orthopedic implant (no and yes); type of
is justified by its repercussion for nurses’ clinical practice
surgical procedure (AMP=amputation; FUS=fusion and
and its possible contribution to the future proposal of
arthrodesis; FX=open fracture reduction; OMS=other
a new nursing diagnosis to NANDA International(14),
musculoskeletal system procedures; nervous
appropriate
system procedures; PROS-Q=hip prosthesis; Other
for
those
situations
that
demand
its
prevention, specifically among surgical patients.
Aims
General: To identify the risk factors associated with
SSI in orthopedic surgical patients at a large general
public hospital in Belo Horizonte, Minas Gerais, Brazil,
between 2005 and 2007, based on the determination of
infection rates.
Specific: To estimate the global incidence level
of SSI for the study period; to identify, among the
variables the Hospital Control Service regularly collects,
those variables that represent risk factors for SSI in
orthopedic patients.
prosthesis like elbow and shoulder); surgery length
(<120 and >120 min) and preoperative hospitalization
time (<04 days and >04 days)(11,13).
To describe and characterize the orthopedic surgery
patients, descriptive analysis with simple frequency
distribution, central trend measures (mean and median)
and variability measures like standard deviation (SD)
and quartiles were used. A global SSI incidence level
was estimated. Univariate analysis was applied to check
the association between SSI and risk factors, using
Mantel–Haenszel’s (c2) Chi-square with Yates’ correction,
Fisher’s exact test and the Chi-square test for Trend. The
strength of the event’s association with the independent
variables was estimated through the Relative Risk (RR),
Methods
with a 95% confidence interval and p<0.05(16).
It should be highlighted that, at the study hospital,
This is a historical cohort of 3,543 patients
submitted to orthopedic surgical procedures, registered
no monitoring for SSI takes place after hospital
discharge.
in a HRI database of a large general public hospital in Belo
Approval for the study was obtained from the
Horizonte, Minas Gerais, Brazil, between January/2005
institution and the Institutional Review Board of the
and December/2007. The surgical patients included in
Instituto de Previdência dos Servidores do Estado de
the study complied with the criteria established in the
Minas Gerais (IPSEMG), protocol 384/2010.
www.eerp.usp.br/rlae
1365
Ercole FF, Franco LMC, Macieira TGR, Wenceslau LCC, Resende HIN, Chianca TCM.
infections were detected, 41 (65%) of which occurred
Results
between the 1st and 69th postoperative day and 22
Characterization
of
study
subjects’
socio-
demographic and clinical variables
diagnosed until the 21st day after the surgery. Thus, the
Among the 3,543 patients submitted to orthopedic
surgical
procedures,
the
mean
age,
preoperative
hospitalization time and surgery length corresponded
to 54 years (SD=19.8), three days (SD=9) and 80.5
minutes
(SD=41.9),
respectively.
(35%) after 90 days. Out of 63 SSI, 31 (49%) were
The
mean
time
interval between the surgery data and infection event
was 95.8 days (SD=115).
global infection incidence level corresponded to 1.8%
for the study period. The most frequent infections were
deep surgical site infections (43%) and osteomyelitis
(33%), totaling 76% of infections. Among all notified
SSIs,
55.6%
involved
surgical
procedures
with
orthopedic implants.
Risk factors for SSI in orthopedic patients
The orthopedic surgical procedures involved 57.7%
of female patients. Among all procedures performed,
Some patient and surgical act characteristics can
in 28.6%, general anesthesia was used. Emergency
influence the risk of developing SSI(2,8-11). In this study,
surgeries were responsible for 0.4% of cases, and
a statistically significant association was found between
implants were placed in 41% of procedures. The
the SSI and some variables (Table 1): surgery length
orthopedic surgeries were ranked as clean wounds
(p=0.01); the contamination potential of the surgical
in 91%, with a 4.6 times smaller risk of infection
wound with p=0.03 (3.6% of SSIs involved surgeries
development when compared with other classifications.
classified as potentially contaminated, contaminated
It was observed that 52.7% of patients were classified
and infected); the patient’s clinical condition – ASA,
as ASA II, with a moderate systematic disease. Most
with <0.00 (SSI risk tended to increase with the
patients (79%) were classified under score zero (absence
patient’s clinical severity); the emergency nature of
of risk factor for infection) of the NNIS Surgical Infection
the surgery (p=0.03) and the presence of orthopedic
Risk Index, followed by score one (18.8%).
implants (p=0.02). No statistically significant difference
was found between the SSI and gender (p=0.07);
Incidence of surgical site infection
NNIS risk index (p=0.18); age (p=0.1); preoperative
In the group of 3,543 patients submitted to
orthopedic
surgical
procedures,
63
surgical
site
hospitalization time (p=0.3) and general anesthesia use
(RR=1.00; 95% CI=1.01-1.03; p=0.00).
Table 1 – Univariate analysis of surgical site infection and independent variables - Belo Horizonte, MG, Brazil,
2005 - 2007
SSI
Variable
Yes (n=63)
No (n=3480)
n
%
n
%
Female
29
46.0
2017
57.9
Male
34
53.9
1463
42.0
Score 0
39
70.9
2710
79.1
Grouped score (1, 2 and 3)
16
29.0
713
20.8
Clean
52
82.5
3174
91.2
Others (PC, C, I)†
11
17.5
306
8.7
No
33
52.3
2495
71.6
Yes
30
47.6
985
28.3
ASA I
11
17.5
1293
37.1
Grouped ASA (II, III , IV and V)
52
82.5
2187
62.8
No
61
96.8
3467
99.6
Yes
2
3.2
13
0.4
RR [95% CI]
p-value
Gender
1.0 [1.0-1.02]
p=0.07
0.60 [0.36-1.15]
p=0.18
0.46 [0.24-0.88]
p=0.03
1.00 [1.01-1.03]
p=0.00
0.36 [0.19-0.69]
p=0.00
1.13 [0.93-1.38]
p=0.03
Surgical Site Infection Risk Index*
Surgical wound contamination potential
General anesthesia
Patient’s clinical conditions (ASA)
Emergency
www.eerp.usp.br/rlae
(continue...)
1366
Rev. Latino-Am. Enfermagem 2011 Nov.-Dec.;19(6):1362-8.
Table 1 – (continuation)
SSI
Variable
Yes (n=63)
No (n=3480)
n
%
n
%
No
28
44
2092
60.1
Yes
35
56
1416
40.6
AMP
2
3.2
23
FUS
3
4.7
81
FX
9
14.3
OMS
29
46
RR [95% CI]
p-value
Orthopedic implant
1.01 [1.0-1.02]
p=0.02
0.6
4.61 [1.19-17.8]
p=0.07
2.3
2.06 [0.66-6.43]
p=0.19
662
19.0
0.71 [0.35-1.44]
p=0.43
2072
59.5
0.58 [0.36-0.95]
p=0.04
Surgical procedure type
ONS
3
4.7
156
4.5
1.06 [0.34-3.36]
p=0.54
PROS-Q
14
22.2
289
8.3
3.06 [1.71-5.47]
p=0.00
Other prostheses (elbow and shoulder)
3
4.7
197
5.7
0.84 [0.26-2.64]
p=0.52
< 120
50
79.4
3069
88.2
0.52 [0.29-0.95]
p=0.01
> 120
13
20.6
411
11.8
< 04 days
47
74.6
1755
50.4
0.71 [0.41-1.25]
p=0.30
> 04 days
16
25.4
725
20.8
Surgery length (min)
Preoperative hospitalization time (days)
*n= 55/3423
† potentially contaminated, contaminated, infected
by the fact that, in more than 40% of the procedures
Discussion
performed, prostheses were implanted, when infections
In this study, the incidence rate of orthopedic SSI
can appear in a late phase, after the patient’s discharge
was low (1.8%). This infection rate is inferior to the
from hospital. Although the CDC recommends surgical
parameters found in some studies about orthopedic
patient monitoring for up to 30 days(5,13), some authors
. A study involving
describe in their research that most surgical site
orthopedic surgery patient information registered in a
infections appear within 21 postoperative days, but can
database found a rate under 1.5%, suggesting data
take up to one year in case of implants(17-18).
SSI, ranging from 5.7 to 22.7%
(6,10,12)
under-notification .
(8)
The most frequent infections were deep surgical
The mean age of the orthopedic surgery patients
was
54
years.
Other
studies
involved
younger
site infection (46%) and osteomyelitis (33%), totaling
populations, with mean ages of 33 to 35 years(8-9). The
79%. Superficial incisional infections contributed were
patient’s mean length of preoperative stay was three
responsible for 21%. Studies describe that superficial
days and the maximum 361 days. The preoperative
incisional infection is the most common surgical site
length of stay did not reveal any association with the
infection(4,12,17-18). In this study, deep infections were
SSI. According to some authors, the preoperative
more frequent.
stay is frequently associated with increased SSI(12-13).
It should be highlighted that infection notifications
Minimizing the hospitalization period before the surgery
were based on an intra-hospital search. At the study
seems to be an important prevention measure, as long
hospital, no control of patients discharged after surgery
hospitalization periods enhance skin colonization by
exists yet. The fact is that patients with severe infections
hospital microbiota(13). Patients who are ill and suffer
tend to be readmitted for a new treatment. The large
from comorbidities should be previously treated, before
majority of superficial infections are normally treated in
the surgical procedure(3,11,13).
the outpatient context and the surgeon does not notify
Surgery length is directly connected with SSI
them. Thus, the epidemiological surveillance service at
events. Surgery length of more than 120 minutes is
the institution does not consider them in its calculations,
a risk factor for infection(6,19-20). Longer surgery length
which can entail under-notification of this event.
means increased tissue exposure time and team
Fifty-one percent (32) of the infections were notified
after the 21st postoperative day. This may be explained
fatigue, enhancing technical errors and decreasing the
organism’s systemic defenses(13).
www.eerp.usp.br/rlae
1367
Ercole FF, Franco LMC, Macieira TGR, Wenceslau LCC, Resende HIN, Chianca TCM.
In this study, patients classified as ASA II were
predominant.
A
study
involving
SSI
in
(p=0.10) and preoperative hospitalization time (p=0.30).
patients
The variables length of surgery, preoperative clinical
submitted to hip surgery also found the same patient
conditions of patient assessed using ASA>2, type of
percentage classified as ASA II
. Patients with systemic
surgical procedure OMS (p=0.04) and PROS-Q (p=0.00),
diseases show a higher incidence rate of SSI, showing
surgical wound contamination potential (contaminated
a direct relation between clinical severity and infection
and infected surgeries) showed to be associated with
events(4,9-10,12). It can be inferred that healthy patients
SSI. In a study of orthopedic infections, the type
are at lesser risk of evolving to an SSI in comparison
of surgical procedure variable showed no statistical
with patients suffering from some kind of disease(12). It is
association with SSI(8). Studies have demonstrated
known that weakening chronic conditions can represent
disagreement as to the association between these risk
risk factors for surgical wound infections, due to the
factors and SSI development(4,6,8-10,12).
host’s low resistance level
(12)
As mentioned, this research identified four SSI
.
(13)
Most orthopedic surgeries were classified as clean
risk factors related with SSI development, which nurses
surgeries (91%), in line with studies that identified
should know about in advance with a view to infection
clean orthopedic surgery percentages ranging between
monitoring and the establishment of early prevention
82.3% and 99%(10,20). A prospective study of orthopedic
measures. Nurses should also take into account other
surgeries
increases
risk factors identified in literature for infection prevention
proportionately to the wound contamination degree(8).
in orthopedic surgeries, such as the use of implantation
A Serbian study of orthopedic surgeries found an SSI
material and the length of preoperative hospitalization.
found
that
the
infection
risk
incidence rate of 13.5% in patients whose surgery was
In turn, it is considered that the identification of SSI
classified as clean, increasing by 70% when the surgery
risk factors can support the proposal of a new nursing
was classified as infected(10).
diagnosis for clinical nursing practice in the surgical
In this study, in turn, no statistically significant
area, which covers patients’ extrinsic and intrinsic
association was found between general anesthesia use
vulnerability to infections by pathogenic microorganisms
in patients submitted to orthopedic surgery and SSI, in
in surgical sites.
line with another Brazilian study(8).
It was identified that most surgical procedures
Conclusions
were elective, without any association between this
variable and the infection. Other authors support this
The SSI incidence rate was 1.8%, below the rate
finding, defining that emergency surgeries do not seem
considered acceptable and described in literature. This
to constitute a risk factor for SSI(8,10). A study about
data might indicate under-notification of the event
infection shows that SSI incidence levels seem to be
under analysis. The most frequent infections were deep
higher after emergency surgeries due to the severity
surgical site infection and osteomyelitis.
of surgical patients, greater difficulty involving the
Surgical wound contamination potential, patient’s
surgical technique and lack of preoperative patient
clinical conditions (ASA), type of surgical procedure and
preparation
surgery length were variables statistically associated
The
.
(13)
use
of
orthopedic
implants
showed
no
with SSI and behaved as risk factors.
association with the SSI. This finding differs from a
Nurses’ knowledge on surgical site infection is
Brazilian study involving orthopedic surgeries(8). The
fundamental to monitor and put in practice pre, peri
presence of an implant is acknowledged for its ability
and postoperative nursing care for surgical patients and
to enhance an infection and develop immune system
can influence clinical practice, as nursing care should
resistance to microbial agents. Also, the type of material
be planned for infection control purposes. It can be
used to make the prosthesis and its design can determine
affirmed that infection rates associated with care are
the bacterial colonization of its surfaces
important patient care quality assessment parameters.
.
(21)
In this study, the following variables showed no
Further research is needed with a view to the
association with SSI: gender (p=0.07), orthopedic
identification and validation of the Nursing diagnosis
implant
Risk
(p=0.02),
general
anesthesia
(p=0.00),
for
Surgical
Site
Infection,
which
NANDA-
emergency (RR=1.13; 95% CI=0.93-1.38; p=0.03),
International is analyzing involving patients in other
NNIS Surgical Infection Risk Index (p=0.18), age
surgical specialties.
www.eerp.usp.br/rlae
1368
Rev. Latino-Am. Enfermagem 2011 Nov.-Dec.;19(6):1362-8.
11. Anderson DJ, Kaye KS, Classen D, Arias KM, Podgorny
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Received: Mar. 4th 2011
Accepted: Sept. 29th 2011
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