Hellenic Journal of Surgery
Surgical Site Infections in Elective Abdominal Operations:
Predisposing Factors. A Prospective Randomized Clinical Trial
Alexiou K, Terzopoulou M, Sikalias N, Bethani D, Ierapetritakis E, Oikonomou N
Hellenic Journal of Surgery (2018) 90:2, 69-74
Alexiou K, Terzopoulou M, Sikalias N, Bethani D,
Ierapetritakis E, Oikonomou N
Department of Surgery, “Sismanoglion-Amalia Fleming”
General Hospital, Athens
Corresponding author: Terzopoulou Maria
Tel. :+30 6944 737021, e-mail. firstname.lastname@example.org
Received Mar 13, 2018; Accepted Mar 23, 2018
Every surgical wound is colonized by bacteria, but
only a small percentage of wounds display symptoms of
infection. The risk of infection increases when a wound is
contaminated by more than 10
microorganisms per gram of
tissue. Surgical site infection (SSI) is the third most common
hospital-acquired infection (HAI), with a rate of 14-16% and
it is the commonest infection in surgical patients. Around
two thirds of SSIs are limited to the surgical incision area
and only one third involve organs and anatomical spaces
that were accessed during the surgical procedure.
The distribution of pathogens isolated from SSIs has
not significantly changed over the last few decades .
Staphylococcus aureus, Coagulase (-) Staphylococcus spp.,
Enterococcus spp. and Escherichia coli are the main strains
recorded to cause SSIs. In addition, a continuously rising
proportion of SSIs caused by resistant bacterial species, such
as methicillin-resistant Staphylococcus aureus (MRSA) and
also Candida albicans, has been reported, which reflects
the increase in immunosupressed and critically ill patients
undergoing surgery, but also the misuse of antibiotics.
In the majority of SSIs the source of pathogens is the
normal microbiota of the skin, mucosa and bowel. Prosthetic
implants can also become sources of bacterial prolifera-
tion. Other external sources include the surgical staff, the
operating room and every machine and instrument used
during the surgical procedure .
SSIs can also be caused by unusual pathogens such
Surgical site infection (SSI) is the third most common hospital-acquired infection (HAI). Specific
patient characteristics and comorbidities appear to be independent prognostic factors for SSIs. In addition, opera-
tion and hospitalization characteristics affect the incidence of SSIs.
This prospective clinical study was conducted in the 1st Department of Surgery of the Sismanoglion
General Hospital of Athens over a period of 7 years. Patients undergoing elective abdominal surgery received an-
timicrobial treatment as chemoprophylaxis. Monitoring of the patients was carried by multiple daily visits during
their hospitalization and continued after they were discharged via phone until postoperative day 30.
During the study period, 31 of the 715 patients undergoing elective abdominal surgery were diagnosed with
SSI, giving an infection rate of 4.3%. The age of the patients with SSIs was significantly higher. Patients with certain
comorbidities, including diabetes mellitus (DM), respiratory deficiency and heart failure (HF), a severity score on
the American Society of Anesthesiologists (ASA) physical status classification system of ASA>3, and those with
concomitant infections had a significantly increased risk of SSIs. SSIs were more common following open surgery
than laparoscopic surgery, and surgery of the lower than the upper gastrointestinal (GI) tract, and postoperative
hemorrhage increased the risk.
There is a paucity of studies assessing the relative contribution of the various predisposing factors to
the incidence of SSIs. In our study, patients with DM, HF, respiratory deficiency, postoperative hemorrhage and
concomitant infections, and patients undergoing lower GI tract operation appeared more prone to SSIs, presenting
this complication 2 to 8 times more frequently. The risk of SSI following laparoscopic surgery was one quarter of
that of open elective abdominal surgery. On the other hand, patients in this series with obesity, renal failure, steroid
intake, radiation therapy, thyroid disease, stomas, previous surgery, intraperitoneal adhesions and inflammatory
bowel disease did not develop SSIs more frequently.
Surgical site infections (SSIs); elective abdominal surgery; surgical chemoprophylaxis; predisposing factors