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Surgical site infection is estimated to occur in roughly 4% of general or vascular operations. Although the type of procedure is the main factor determining the risk of developing a surgical site infection, certain patient factors have been associated with increased risk, including diabetes mellitus, older age, obesity, heavy alcohol consumption, admission from a long-term care facility, and multiple medical comorbidities. For most major procedures, the use of prophylactic antibiotics has been demonstrated to reduce the incidence of surgical site infections significantly. For example, antibiotic prophylaxis in colorectal surgery reduces the incidence of surgical site infection from 25–50% to below 20%. In addition, in a case-control study of Medicare beneficiaries, the use of preoperative antibiotics within 2 hours of surgery was associated with a twofold reduction in 60-day mortality. Several general conclusions can be drawn from studies of different antibiotic regimens for surgical procedures. First, substantial evidence suggests that a single dose of an appropriate intravenous antibiotic—or combination of antibiotics—is as effective as multiple-dose regimens that extend into the postoperative period. Second, for most procedures, a first-generation cephalosporin is as effective as later-generation agents. Third, prophylactic antibiotics should be given intravenously at induction of anesthesia or roughly 30–60 minutes prior to the skin incision.

Other strategies to prevent surgical site infections have proven to be controversial. Evidence suggests that nasal carriage with Staphylococcus aureus is associated with a twofold to ninefold increased risk of surgical site and catheter-related infections in surgical patients. In several studies of patients with nasal colonization by S aureus, treatment with 2% mupirocin ointment (twice daily for 3 days) before surgery reduced the risk of surgical site infection by this organism. However, the ideal strategy for detecting and treating nasal colonization remains uncertain. High-concentration oxygen delivered in the immediate postoperative period may reduce surgical site infections in patients undergoing colorectal surgery or operations requiring general anesthesia. The use of razors for hair removal actually seems to increase the risk of surgical site infections and is therefore specifically not recommended. If preoperative hair removal is indicated, the use of clippers is preferred.

Guidelines for antibiotic prophylaxis against infective endocarditis in patients undergoing invasive procedures are presented in Chapter 33-09. Given the lack of evidence for antibiotic prophylaxis against prosthetic joint infection before dental procedures, guidelines from the American Academy of Orthopedic Surgeons and the American Dental Association recommend against this practice.

Berríos-Torres  SI  et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784–91.
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Najjar  PA  et al. Prophylactic antibiotics and prevention of surgical site infections. Surg Clin North Am. 2015 Apr;95(2):269–83.
[PubMed: 25814106]
Young  H  et al. Dental disease and periprosthetic joint infection. J Bone Joint Surg Am. 2014 Jan 15;96(2):162–8.
[PubMed: 24430417]

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