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ORIGINAL
Usefulness of a multidisciplinary surgical site infection teamin colorectal surgery
Shohei Eto, Kozo Yoshikawa, Yukako Takehara, Toshiaki Yoshimoto, Chie Takasu, Hideya Kashihara, Masaaki Nishi,
Takuya Tokunaga, Toshihiro Nakao, Jun Higashijima, Takashi Iwata, and Mitsuo Shimada
Department of Surgery, Graduate School of Medical Sciences, Tokushima University, Tokushima, Japan

Abstract : Background : Surgical site infection (SSI) is an adverse event that places a major burden on patientsand staff. In this study, we examined the occurrence of SSI and the characteristics of patients referred to the
SSI team after colorectal surgery. Methods : In total, 955 patients underwent colorectal surgery at our hospitalfrom 2014 to 2019. Of these 955 patients, 516 received therapeutic support by the SSI team from 2017 to 2019. All
patients were evaluated using an SSI surveillance sheet, and we checked for reports of SSI once a month. Eachattending physician performed SSI prophylaxis (use of new instruments before wound irrigation and closure).
Results : SSI occurred in 80 (8.4%) patients. The incidence of SSI and the incidence of surface SSI were higher inthe patients who did not receive intervention by the SSI team than in the patients who did. Organ / space SSI occurred in 18 patients. Among patients with surface SSI, Enterococcus was the most commonly detected bacteria.
Among the 18 patients with organ / space SSI, 5 developed anastomotic leakage and 4 developed intra-abdominal
abscesses. Conclusions : An SSI team for prevention and treatment of infection may contribute to reduction of
SSI. J. Med. Invest. 68 : 256-259, August, 2021
Keywords : surgical site infection, colorectal surgery, infection control team, stoma closure

INTRODUCTION
Risk management in hospitals has become important for
prevention of accidents involving medical staff and patients. Surgical site infection (SSI) is a surgery-related adverse event thatplaces a major burden on patients and staff. Therefore, reductionof the incidence and increased awareness of SSI are importantin medical institutions (1-4). The risk of infection after colorectal
surgery has increased during recent years because of the aging
of society and a higher number of immunocompromised hosts,
and treatment of this infection can be difficult (5-10). To address
this problem, formation of an infection control team (ICT) may
be useful for prevention of infection and therapeutic collaboration(11). In our hospital, SSI prevention has been performed by an
SSI team since 2017. The team includes five doctors, four nurses(ICT and operation room), one pharmacist, and one clinical microbiologist. The ICT is responsible for infection prevention andcontrol as well as support for treatment of health care-associatedinfections. This study was performed to examine the occurrenceof SSI and the characteristics of patients referred to the SSI
team after colorectal surgery and to describe the practical implementation of infection prevention and control measures.

PATIENTS AND METHODS
In total, 955 patients underwent colorectal surgery at our
hospital from 2014 to 2019. Of these 955 patients, 516 received
therapeutic support by the SSI team from 2017 to 2019 ; the remaining 439 patients did not (2014-2016). Patients who underwent
Received for publication April 6, 2021 ; accepted April 19, 2021.
Address correspondence and reprint requests to Kozo Yoshikawa,
MD, Department of Surgery, Graduate School of Medical Sciences,
University of Tokushima, 3-18-15 Kuramoto-cho, Tokushima 7708503, Japan and Fax : +81-88-631-9698.

emergency surgery and peritonitis surgery were excluded fromthis study. The patients’ pathogenic bacteria and treatments
were retrospectively examined. SSI conferences were held by the
SSI team. All patients were evaluated using an SSI surveillance
sheet, and we checked for reports of SSI once a month. The incidence of SSI among the patients was also examined.
The study protocol was approved by the ethics committee ofTokushima University Graduate School of Medicine (TOCMS
3215).

Improvements
Each attending physician performed SSI prophylaxis basedon empirical data (4, 12-22). An SSI conference was held oncea month to check for any reports of SSI and discuss methods
for improvement. For SSI prevention, the surgeon first changed
gloves and obtained new instruments before closing the wound.
The wound was then irrigated by syringe pressure irrigation(100 mL) and pouring of irrigation fluid over the wound (500mL). Finally, interrupted suture closure was performed with
antibiotics and absorbable thread. Circular sutures were appliedin patients requiring stoma closure.
In all patients, surgical prophylaxis was performed using
evidence-based standards and guidelines, such as injection of afirst-generation cephalosporin within 1 hour before incision anddiscontinuation of prophylaxis within 48 hours after surgery.
Antibiotics proposed by the ICT were used in all patients who
were treated with ICT assistance, and selection of the antibiotics was performed at the discretion of the ICT until bacteria
were no longer detected. In patients undergoing surgery with
instrumentation, vancomycin or linezolid was selected as theinitial treatment if gram-positive cocci were found in a woundsmear test. De-escalation to narrow-spectrum antimicrobial
agents with relatively few side effects was performed if causative
bacteria were identified and drug susceptibility was revealed,depending on the patient’s clinical symptoms. In patients withmethicillin-resistant staphylococci, long-term sulfamethoxazole /trimethoprim and rifampicin were used to treat the infection

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The Journal of Medical Investigation Vol. 68 August 2021
until bacteria were no longer detected.
The effectiveness of SSI control by the ICT was evaluated byexamining the origins of infection found by ICT collaboration,
the causative bacteria, and the detection rates of methicillin-resistant bacteria in all patients with SSI and in those with SSI
after surgery using instrumentation.

Statistical analysis
The statistical analysis was performed using statistical software (JMP 8.0.1 ; SAS Institute Cary, NC, USA). The Mann–
Whitney U test was used to compare continuous variables, andthe chi-square test was used to compare categorical data. Statistical significance was defined as p < 0.05.

RESULTS
In total, 955 patients (colon / rectum / stoma : 660 / 142 / 153
patients, respectively) were retrospectively analyzed (Table
1). Among these patients, 516 received intervention by the
SSI team (after group). SSI occurred in 80 (8.4%) patients(colon / rectum / stoma : 45 / 16 / 19 patients, respectively). The
incidence of SSI tended to be higher among the patients who
did not receive intervention by the SSI team (before group)
than in the after group [49 / 439 (11.1%) vs. 31 / 516 (6.0%), respectively ; p = 0.09]. The patients’ characteristics (age, sex,
location, open surgery / laparoscopy, body mass index, blood loss,
operation time, comorbidity, and use of drainage tube) were notsignificantly different between the two groups. A total of 62 patients developed surface SSI. During the course of the study, theincidence of surface SSI decreased from 8.7% (38 / 439 patients)
in the before group to 4.7% (24 / 516 patients) in the after group(p = 0.01). Eighteen patients developed organ / space SSI (before
group, n = 11 ; after group, n = 7 ; p = 0.19).
Comparison of the patients with and without SSI in the after
group showed no significant differences in the patients’ characteristics (age, sex, location, open surgery / laparoscopy, body
Table 1. Patients’ characteristics
Factor

Before (n = 439) After (n = 516) p valueAge (years)

70.8 ± 6.4

71.6 ± 5.6

0.23

Sex (male / female)

262 / 177

309 / 2070.31

colon / rectum / stoma

288 / 74 / 77

372 / 68 / 76

0.25Open / Laparoscopy

148/291

193 / 323

0.19

Location

BMI

24.4 ± 2.7

23.8 ± 2.5

0.55

Blood loss

25.1 ± 8.1

22.9 ± 6.5

0.33

Operation time (min)226 ± 28215 ± 35

0.18

Comorbidity
Hypertension / DM

129 / 48

161 / 67

0.22

Drainage tube +/-147 / 292

155 / 361

0.24

SSI

49

31

0.09

Surface / Organ・Space38 / 1124 / 7

0.31

Colon

23

22

0.30

Reutum

8

8

0.34

Stoma

18

1

0.05

Data are presented as mean ± standard deviation or number of patients.
BMI body mass index
DM diabetes mellitus
SSI surgical site infection

mass index, blood loss, operation time, comorbidity, and use ofdrainage tube) (Table 2).
Among patients with surface SSI, Enterococcus was the mostcommonly detected bacteria (Table 3). Enterobacter, Escherichia
coli, Bacteroides, and Candida were also detected. Among patientswith organ / space SSI, five patients developed anastomotic leakage and four patients developed intra-abdominal abscesses. Escherichia coli and Enterococcus were detected by bacterial culture.
No multidrug-resistant bacteria were found in this study.

Table 2. Comparison of SSI and non-SSI (after SSI intervention)
SSI (n = 31)

Non-SSI (n = 485) p valueAge (years)

70.2 ± 7.4

72.4 ± 5.8

0.17

Sex (male / female)

19/10

289 / 196

0.26

BMI

24.6 ± 4.7

22.9 ± 3.4

0.13

FactorBlood loss (g)20.7 ± 6.1

23.3 ± 7.1

0.38

Operation time (min)221 ± 28

211 ± 25

0.23

Open / Laparoscopy

9 / 22184 / 301

0.20

Drainage tube +/-15 / 1682 / 173

0.12

Surface / Organ・Space

24 / 7

Data are presented as mean ± standard deviation or number ofpatients.
SSI surgical site infection
BMI body mass index

Table 3. Bacteria detected in patients with SSI
Bacteria

SSI (n = 29)

Enterococcus

14Enterobacter

9E. coli

4Bacteroides

4

Candida2

Data are presented as number of patients.
SSI surgical site infection

DISCUSSION
SSI is the most common and costly of all hospital-acquired
infections, accounting for 20% of such infections (4). Surgicalsite infections are associated with an increased length of stay
and a 2- to 11-fold increase in the risk of mortality. Althoughmost patients recover from an SSI without long-term adverse
sequelae, death in 77% of patients with an SSI can be attributed
to the infection itself. The incidence of SSI ranges from 2% to 5%
in patients undergoing inpatient surgery. These estimates arelikely underestimated given the surveillance challenges after
discharge (7, 8, 23-27).
Numerous risk factors for the development of SSI have been
identified. These risk factors can be broadly separated into
intrinsic and extrinsic factors. Intrinsic factors are patient-related factors that may be either modifiable or nonmodifiable,
and extrinsic factors comprise procedure-related, facility-related, preoperative, and operative factors. Potentially modifiable
patient-related risk factors include the glycemic control anddiabetic status, dyspnea, the alcohol and smoking status, alow preoperative albumin concentration, a high total bilirubin
concentration, obesity, and immunosuppression. Nonmodifiable

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S. Eto, et al. Usefulness of infection team in CRS

patient-related factors include increasing age, recent radiotherapy, and a history of skin or soft tissue infection. Procedure-related factors include emergency and more complex surgery andthe wound classification. Facility-related risk factors include
inadequate ventilation, increased operating room traffic, andappropriate sterilization of equipment. Preoperative risk factors include pre-existing infection ; inadequate skin preparation ; hair removal ; and the choice, administration, and durationof antibiotics. Intraoperative risk factors include the duration ofsurgery, blood transfusion, maintenance of asepsis, poor-quality
surgical hand scrubbing and gloving, hypothermia, and poor
glycemic control (7, 8, 28). In the present study, however, there
was no significant difference between two groups.
For SSI prevention, the gloves were changed and new instruments were obtained before closing the wound. The wound wasthen thoroughly irrigated. Finally, interrupted sutures wereplaced with antibiotics and absorbable thread (12-14). Circularclosure after stoma reversal has a lower risk of stoma site SSI
than does conventional primary closure, although wounds may
take longer to heal with the use of this approach (18). Appropriate surgical techniques have resulted in a lower incidence of
SSI ; therefore, we decided to adopt the same methods.
A previous study showed that multidisciplinary care orcase-relevant communication reduced the incidence of SSI inpatients undergoing digestive surgery (11, 27). We formed an
SSI team based on these guidelines and started an initiative
to reduce SSI (4). Previously, each surgeon used his or her own
operative technique. The SSI team intervened and unified theprocedures. The surgeons were made aware of the risks of wound
infection, the increased cost of care, and the need for appropriate
prevention. We then reviewed the patients with SSI and developed a surveillance sheet to identify the incidence and organisms
by technique. In addition, appropriate use of antibiotics was established in collaboration with the ICT. Notably, we found a significant decrease in the incidence of surface SSI after colorectal
surgery by using the correct wound closure techniques and SSI
team intervention. However, the incidence of deep (organ / space)
infection was not significantly changed by intervention from the
SSI team. The occurrence of deep infection, such as leakage orintra-abdominal abscesses, was thought to be due to factors associated with the surgical technique.
Limitations of this study are its retrospective design and low
number of patients. Furthermore, the patients’ nutritional andgeneral conditions were not examined.
In conclusion, SSI is difficult to completely prevent, even withmany preventive measures in place. Intervention by our SSI
team tended to reduce the incidence of SSI, and this may leadto reductions in the length of hospital stay and medical costs. In
the future, it may be important to examine risk factors and to
consider not only surgical techniques but also preoperative interventions for high-risk patients to reduce the overall incidence of
SSI. However, collaboration with an SSI team for prevention andtreatment of infection may contribute to reduction of SSI.

CONFLICT OF INTERESTS-DISCLOSURE
The authors have no conflicts of interest directly relevant tothe content of this article.

ACKNOWLEDGEMENTS
We thank Angela Morben, DVM, ELS, from Edanz Group(https://en-author-services.edanz.com/ac), for editing a draft ofthis manuscript.

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