https://doi.org/10.53453/ms.2025.6.2
Surgical site infections: etiology, risk factors, and preventive
measures – a literature review
Ieva Bružaitė
1
, Linas Prapiestis
1
, Dalius Malcius
2
1
Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania
2
Lithuanian University of Health Sciences, Kaunas Clinics, Department of Paediatric Surgery, Kaunas, Lithuania
Abstract
Background. Surgical site infections (SSIs) are a leading cause of postoperative complications, affecting up to
11% of surgical patients globally. They result from microbial contamination of wounds and are influenced by
patient health, surgical technique, and healthcare conditions.
Aim. To evaluate current knowledge on surgical site infections, including epidemiology, risk factors,
pathogenesis, diagnostic approaches, treatment, preventive strategies.
Material and Methods. A comprehensive literature review was conducted using the PubMed database, focusing
on English-language studies, more than 70% of the articles referenced were published between 2015 and 2025.
Studies were selected based on relevance to epidemiology, pathogenesis, risk factors, diagnosis, and treatment.
Results. Studies show that longer surgeries, poor antisepsis, obesity, and uncontrolled blood sugar increase SSI
risk. Rates are highest in low- and middle-income countries. Preventive strategies like timely antibiotics, antiseptic
protocols, and negative pressure wound therapy help reduce incidence, though misuse of antibiotics and resistant
organisms remain major challenges.
Conclusion. SSIs remain a significant health burden despite preventive advances. Tackling them requires strict
infection control, better diagnostic tools, and responsible antibiotic use. Future efforts should focus on biofilm-
targeting therapies, risk prediction models, expanding minimally invasive surgery to improve outcomes
worldwide.
Keywords: surgical site infections, infection control, surgical wound management, antimicrobial resistance,
biofilm formation.
Journal of Medical Sciences. 4 Jun, 2025 - Volume 13 | Issue 4. Electronic - ISSN: 2345-0592
Medical Sciences 2025 Vol. 13 (4), p. 8-18, https://doi.org/10.53453/ms.2025.6.2
8
Pooperacinės žaizdos infekcijos: etiologija, rizikos veiksniai ir
prevencinės priemonės – literatūros apžvalga
Ieva Bružaitė
1
, Linas Prapiestis
1
, Dalius Malcius
2
1
Lietuvos sveikatos mokslų universitetas, Medicinos fakultetas, Kaunas, Lietuva
2
Lietuvos sveikatos mokslų universitetas, Kauno klinikos, Vaikų chirurgijos klinika, Kaunas, Lietuva
Santrauka
Įvadas. Chirurginės žaizdos infekcijos (SSI) yra viena pagrindinių pooperacinių komplikacijų priežasčių,
paveikiančių iki 11 % pacientų visame pasaulyje. Jos atsiranda dėl mikrobinio žaizdų užteršimo, kurį lemia
paciento sveikatos būklė, chirurginė technika ir sveikatos priežiūros sąlygos.
Tyrimo tikslas. Atlikti išsamią pooperacinių infekcijų apžvalgą, vertinant naujausias žinias apie epidemiologiją,
rizikos veiksnius, patogenezę, diagnostikos metodus, gydymo galimybes ir prevencijos strategijas.
Medžiaga ir metodai. Išsamiai išanalizuota mokslinė literatūra, pasitelkus PubMed duomenų bazę. Į analizę
įtraukti tik anglų kalba publikuoti tyrimai, daugiau nei 70% literatūros šaltinių paskelbti 2015–2025 m. Atrinkti
tyrimai buvo vertinami pagal jų svarbą epidemiologijos, patogenezės, rizikos veiksnių, diagnostikos ir gydymo
sričiai.
Rezultatai. Ilgesnės operacijos, prasta antiseptika, nutukimas, nekontroliuojamas cukraus kiekis kraujyje didina
SSI riziką. Didžiausi rodikliai yra mažų ir vidutinių pajamų šalyse. Prevencinės strategijos, tokios kaip laiku
skiriami antibiotikai, antiseptikos protokolai ir neigiamo slėgio žaizdų terapija, padeda sumažinti sergamumą,
nors piktnaudžiavimas antibiotikais ir atsparūs organizmai tebėra didelės problemos.
Išvados. Nepaisant pažangos prevencijos srityje, su sveikatos priežiūra susijusios infekcijos tebėra didelė našta.
Norint jų sumažinti, reikia griežtos infekcijų kontrolės, geresnių diagnostikos priemonių, racionalaus antibiotikų
vartojimo. Ateityje daugiausia dėmesio turėtų būti skiriama į bioplėvelę nukreiptiems gydymo būdams, rizikos
prognozavimo modeliams, minimaliai invazinės chirurgijos plėtrai, siekiant pagerinti rezultatus visame pasaulyje.
Raktažodžiai: chirurginės infekcijos, infekcijų kontrolė, chirurginių žaizdų tvarkymas, atsparumas
antimikrobinėms medžiagoms, bioplėvelės susidarymas.
Journal of Medical Sciences. 4 Jun, 2025 - Volume 13 | Issue 4. Electronic - ISSN: 2345-0592
9
1. Introduction
Healthcare-associated infections remain a major
global challenge, undermining patient safety and
burdening healthcare systems. Among these,
surgical site infections (SSIs) are among the
most frequent and serious complications
following operative procedures. They
significantly contribute to postoperative
morbidity, extended hospital stays, and
increased healthcare costs worldwide (1).
SSIs result from microbial contamination of a
surgical wound during or after a procedure and
are influenced by factors such as environmental
sterility, operative technique, and patient
condition. They are classified based on the depth
and site of infection: superficial incisional,
involving the skin and subcutaneous tissue; deep
incisional, affecting deeper soft tissues such as
muscle and fascia; and organ/space infections,
involving internal organs or anatomical spaces
manipulated during surgery (2). According to the
Centers for Disease Control and Prevention
(CDC), an SSI is defined as an infection
occurring within 30 days of a surgical procedure,
or within one year if an implant or prosthetic
material was placed (3).
The clinical significance of SSIs extends beyond
the immediate infection. Particularly challen-
ging are wounds healing by secondary intention,
which are slower to resolve and more prone to
complications. These cases demand a focused
approach to wound care, early identification of
risk factors, and implementation of modern
evidence-based prevention strategies (4).
2. Methods
A comprehensive literature review was
conducted using the PubMed database to
identify relevant studies on surgical site
infections, epidemiology, risk factors, patho-
genesis, diagnostic approaches, treatment
options, and preventive strategies. The search
strategy employed a combination of keywords,
including "Surgical site infections”, “Postope-
rative infection”, “Infection control”, “Surgical
wound management”, “Postoperative Complica-
tions”, “Antimicrobial Resistance”. In total, 43
articles were included in the review based on
their compliance with the established inclusion
criteria.
Inclusion criteria:
● To ensure the inclusion of recent and
up-to-date findings, at least 70% of the
articles referenced were published
between 2015 and 2025.
● Publications written in English.
● Peer-reviewed original research
articles, systematic reviews, meta-
analyses, and clinical guidelines.
● Studies focused on the epidemiology,
risk factors, pathogenesis, diagnosis,
treatment, or prevention of surgical site
infections.
● Studies involving human subjects.
Exclusion criteria:
● Articles published in languages other
than English.
● Articles lacking accessible full text.
The application of additional filters allowed for
the inclusion of studies addressing epidemio-
logy, risk factors, pathogenesis, diagnosis,
treatment, and prevention of surgical site
infections. Following the application of the
predefined inclusion and exclusion criteria, a
selection of the most relevant studies was made.
This systematic approach ensures a thorough and
up-to-date evaluation of the current knowledge
and advancements in the management of
surgical site infections.
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10
3. Results
3.1 Epidemiology and risk factors
Surgical site infections continue to be a global
health concern, with incidence rates significantly
varying by region, healthcare infrastructure,
surgical specialty, and patient-related factors. A
comprehensive meta-analysis involving 57
studies and nearly 489,000 patients found that
the pooled 30-day incidence of SSIs was
approximately 11%, with notable variation by
anatomical site and urgency of the procedure.
Duration of surgery was independently
associated with increased infection risk (5).
Similar findings by Allegranzi and othersin a
WHO-sponsored review noted an increased risk
in procedures exceeding two hours, particularly
in emergency surgeries (6).
Risk factors for SSIs are commonly categorized
as patient-related and procedure-related. Patient-
based factors include age, poor nutritional status,
diabetes mellitus, smoking, obesity, immune
suppression, and prolonged hospital stay before
surgery, which may compromise wound healing
or systemic immunity (7,8). Procedural risk
factors include improper antisepsis, inadequate
antimicrobial prophylaxis, longer surgery dura-
tion, poor wound classification, suboptimal sur-
gical technique, and use of foreign materials (7).
Material selection during surgery also influences
infection risk. Multifilament and non-absorbable
sutures are more prone to bacterial colonization
and biofilm formation compared to
monofilament and absorbable options. Sutures
act as potential reservoirs for pathogens,
especially in cases involving implants, further
emphasizing the need for antimicrobial or coated
suture technologies (9,10).
Environmental and institutional factors—such as
operating room ventilation, sterilization
practices, and surgical team adherence to
hygiene protocols—play a pivotal role in SSI
prevention. High surgical staff turnover and
suboptimal infection control policies further exa-
cerbate the risk in under-resourced settings (6).
3.2 Pathogenesis and microbiota
The development of surgical site infections is a
multifactorial process involving microbial
colonization, host immune response, and
environmental exposure during or after surgery.
Most SSIs originate from the patient’s
endogenous microbiota—primarily from the
skin, gastrointestinal tract, or mucosal
surfaces—which gain access to the surgical
wound either during the procedure or in the
immediate postoperative period (11). The
spectrum of pathogens isolated from SSIs
depends largely on the type of surgical
procedure, anatomical location, and healthcare
setting. Based on contemporary surveillance
data from the National Healthcare Safety
Network, the most frequently identified
pathogens include Staphylococcus aureus (both
methicillin-sensitive and methicillin-resistant),
Escherichia coli, Enterococcus faecalis,
Pseudomonas aeruginosa, and coagulase-
negative staphylococci (12). Alarmingly, only
23% of the pathogens were sensitive to the
prophylactic antibiotics administered
preoperatively, reflecting the growing challenge
of antimicrobial resistance. The increasing
emergence of multidrug-resistant organisms,
including MRSA and vancomycin-resistant S.
aureus, has further complicated SSI
management, often necessitating broad-
spectrum or targeted antimicrobial therapy (13).
The prevalence of Methicillin-resistant
Staphylococcus aureus (MRSA) in surgical site
infections varies significantly depending on
region, hospital practices, and national
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11
healthcare infrastructure. In countries like the
United States and parts of Europe, MRSA
accounts for 10–20% of SSIs, while in lower-
resource settings such as Pakistan, Ukraine, it
can exceed 30–40% due to inadequate infection
control and inconsistent antibiotic protocols
(14,15). MRSA-related SSIs are most commonly
reported in orthopedic, abdominal, and trauma
surgeries, particularly in adults. In contrast,
MRSA prevalence in pediatric surgical patients
is generally low, especially in cardiac and
general surgeries, where structured infection
prevention bundles and preoperative screening
are routinely applied (16). This suggests that
targeted interventions in pediatric settings are
effective in keeping MRSA SSI rates minimal.
A significant portion of infections, particularly
chronic and relapsing ones, are now understood
to be associated with biofilm formation.
Biofilms are complex microbial communities
embedded within an extracellular polymeric
matrix composed of polysaccharides, proteins,
lipids, and extracellular DNA. These structures
adhere to both biological tissues and medical
devices, such as catheters, sutures, and implants
(17). Biofilm-associated bacteria exhibit
markedly enhanced resistance to antimicrobial
agents—up to 1000 times more than planktonic
cells—due to impaired antibiotic penetration,
metabolic dormancy of cells, and the presence of
specialized persister phenotypes (18). Biofilm
formation follows a multi-phase process: initial
adhesion, microcolony formation, maturation,
and dispersion. The final phase is critical, as
detached cells from mature biofilms can
colonize new sites, potentially leading to
systemic infection (19). Notably, biofilms also
promote horizontal gene transfer, facilitating the
spread of resistance traits among bacterial
populations in the wound bed (20).
Consequently, traditional antimicrobial therapy
is often ineffective, and removal of infected
implants or debridement becomes necessary in
chronic SSI cases.
Understanding the microbial ecology of surgical
wounds and the molecular mechanisms of
biofilm formation is therefore essential for
developing more effective prevention and
treatment approaches.
3.3 Diagnosis of surgical site infections
Diagnosing surgical site infections requires a
multifaceted approach integrating clinical
judgment, physical examination, imaging, and
laboratory findings. Common clinical features
include localized erythema, warmth, edema,
incisional pain, and purulent discharge (21).
Deeper infections may manifest with systemic
signs such as fever, malaise, leukocytosis, and
elevated inflammatory markers (22). Organ-
space infections, which may initially lack
cutaneous signs, often require imaging for
detection and confirmation. The physical
examination should be comprehensive and
ideally in person, with all dressings removed to
assess wound characteristics such as fluctuance,
necrosis, or ischemia. Sterile probing may reveal
dead spaces or fluid pockets suggestive of deeper
involvement (23).
Imaging modalities are invaluable for
diagnosing deep or organ/space SSIs.
Ultrasound is useful for detecting abscesses,
guiding aspiration, and identifying fluid
collections. X-rays may reveal gas in soft tissues
or suggest osteomyelitis. Computed tomography
(CT) provides rapid evaluation of fluid
collections and necrotic changes, while magnetic
resonance imaging (MRI) is superior for
detecting fascial and muscular involvement,
especially in suspected necrotizing soft tissue
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12
infections (24,25). MRI is considered the gold
standard in differentiating cellulitis from
necrotizing fasciitis when clinical signs are
inconclusive.
Laboratory diagnostics support clinical
suspicion but should not delay intervention.
Elevated white blood cell counts, C-reactive
protein (CRP), and procalcitonin are common
findings, especially in systemic or deep
infections. CRP levels on postoperative day 3–4
have demonstrated utility in predicting SSIs,
with elevated levels correlating with increased
infection risk (26).
Microbiological confirmation, when possible, is
critical for guiding therapy. Superficial wound
swabs may be contaminated by skin flora and are
generally less reliable. Deep tissue cultures,
obtained via aspiration or biopsy, yield higher
diagnostic accuracy and are especially important
in suspected multidrug-resistant infections.
Blood cultures are reserved for patients with
systemic symptoms or suspected bacteremia
(27). For patients with necrotizing infections—
such as Fournier gangrene—rapid surgical
exploration remains the cornerstone of
diagnosis, with imaging and labs serving a
supportive role.
Finally, several risk stratification tools aid in
predicting SSI likelihood, including the National
Nosocomial Infection Surveillance index and
procedure-specific scores like the Surgical Site
Infection Risk Score. Although useful, many
tools omit nuanced patient and surgery-specific
factors, limiting their predictive power (28).
3.4 Prevention of surgical site infections
The prevention of surgical site infections
requires a multifaceted strategy encompassing
preoperative, intraoperative, and postoperative
interventions, each tailored to address specific
modifiable risk factors.
3.4.1 Preoperative measures
Preoperative strategies are critical to minimizing
microbial contamination at the time of incision.
Hair removal, if necessary, should be performed
using electric clippers rather than razors to
reduce microscopic skin trauma and subsequent
bacterial entry. This should be done as close to
the time of surgery as possible and outside the
operating room (29). Glycemic control is equally
important; perioperative hyperglycemia, even in
non-diabetic patients, significantly increases SSI
risk. Current recommendations suggest
maintaining intraoperative glucose levels below
10 mmol/l, with tighter control (≤8,33 mmol/l)
showing additional benefit without added
mortality, although hypoglycemia risk remains a
concern (30).
Nutritional status also plays a crucial role, as
malnutrition impairs immune function, delays
wound healing and increases the likelihood of
chronic wound formation. Studies confirm that
patients with adequate nutrition experience
faster healing and shorter hospital stays (30).
Obesity (BMI >30) presents another major risk
factor, impairing tissue oxygenation and
reducing the effectiveness of antimicrobial
prophylaxis due to altered drug distribution and
metabolic demands (21). Antimicrobial
prophylaxis—typically with first- or second-
generation cephalosporins—should be
administered intravenously 30 to 60 minutes
before incision.
3.4.2 Intraoperative measures
During surgery, strict adherence to aseptic
techniques is vital. Skin antisepsis using
chlorhexidine gluconate (CHG)-alcohol
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13
solutions has demonstrated superior efficacy
over povidone-iodine in reducing bacterial load
and SSI incidence, though combining these
agents may further improve outcomes (31).
Surgical site irrigation with sterile saline,
maintenance of normothermia, and minimi-
zation of intraoperative contamination (e.g.,
through wound protectors and antimicrobial-
coated sutures) have all been shown to
significantly reduce infection rates (32).
Antibiotic prophylaxis should not extend beyond
24 hours postoperatively, as prolonged use offers
no added benefit, increases C. difficile risk, and
contributes to antimicrobial resistance (30).
3.4.3 Postoperative Measures
Postoperatively, the focus shifts to wound care
and early complication detection. Non-touch
techniques and the use of sterile saline for wound
cleansing are the gold standard in immediate
postoperative care. After 48 hours, patients can
typically begin showering with soap, but topical
antimicrobials are generally discouraged unless
clinically indicated, as they do not significantly
reduce SSI risk (33). Dressing materials also
influence outcomes—recent meta-analyses
suggest that VE-silicone and mupirocin-
impregnated dressings may be superior to
conventional dressings in reducing infection
incidence (34). Negative-pressure wound
therapy (NPWT) is another adjunct shown to
reduce postoperative wound complications,
particularly in high-risk or contaminated
surgeries (32).
3.5 Treatment of surgical site infections
The treatment of surgical site infections
involves a multifaceted approach encompassing
empirical and targeted antibiotic therapy,
surgical wound management, and adjunctive
interventions like NPWT. Empirical antibiotic
therapy is crucial in the early management of
SSIs, particularly in cases of systemic
involvement such as sepsis. Studies show that
timely empiric antibiotic administration—
preferably within the first hour—can
significantly reduce mortality in septic shock
and severe infections (35). Once culture and
sensitivity data become available, targeted
antibiotic therapy should be initiated to
minimize the risk of resistance and optimize
outcomes (36).
Surgical site care is fundamental, especially in
purulent or deep infections. Superficial
infections may require simple drainage and
debridement, while deep incisional or
organ/space infections necessitate thorough
drainage, removal of necrotic tissue, and
sometimes hardware or suture removal (3).
In more complex or chronic cases, Negative
Pressure Wound Therapy (NPWT) has emerged
as a valuable tool. It enhances local perfusion,
promotes angiogenesis, and accelerates
granulation tissue formation. A systematic
review of studies, including randomized
controlled trials and cohort analyses, reported a
reduction in infection rates, serohematoma
formation, and reoperation rates with NPWT,
particularly in high-risk surgical wounds
(37,38). However, NPWT must be preceded by
surgical debridement and appropriate antibiotic
coverage for optimal efficacy and safety.
Antimicrobial resistance poses a growing
challenge in SSI management. Methicillin-
resistant Staphylococcus aureus remains a
leading cause of SSIs, particularly in hospital
settings. Empirical treatment for complicated
SSIs often includes vancomycin, linezolid, or
daptomycin, while outpatient cases involving
community-acquired MRSA (CA-MRSA) can
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14
be managed with clindamycin, doxycycline, or
trimethoprim-sulfamethoxazole (39). Resistance
patterns also influence therapy for streptococcal
infections; although macrolide resistance is
rising, β-lactams like penicillin remain effective
against group A Streptococcus (36). In life-
threatening infections such as necrotizing
fasciitis caused by S. pyogenes, high-dose
penicillin combined with clindamycin remains
the treatment of choice.
3.6 Outcomes, complications, and future
directions in surgical site infections
Surgical site infections remain a significant
burden on patients and healthcare systems,
leading to serious clinical and economic
consequences. Studies show that methicillin-
resistant Staphylococcus aureus -associated SSIs
following colorectal surgery can extend hospital
stays by nearly 20 days (40). Tuon and others
also reported a mortality rate of 5.4% due to SSIs
related to orthopedic trauma, highlighting the
severity of such infections (41). Beyond
mortality, SSIs are major contributors to hospital
readmissions and reoperations, particularly in
procedures involving prosthetic implants or
secondary wound healing (42).
Long-term complications can include persistent
purulent discharge, abscess or hematoma
formation, and chronic wound inflammation,
which impair quality of life and increase
dependency on healthcare resources. Chronic
wounds, including those evolving from poorly
managed SSIs, often remain trapped in the
inflammatory phase of healing (43).
4. Conclusion
Surgical site infections remain a major
complication in surgical care, driven by a
complex interplay of microbial, patient-related,
procedural, and environmental factors. Their
impact is particularly severe in low-resource
settings, where infrastructure and perioperative
practices are often suboptimal. SSIs prolong
hospitalization, increase costs, worsen
outcomes, and are further complicated by the
rise of antimicrobial resistance—especially from
MRSA and other multidrug-resistant pathogens.
While standard treatments like timely
antibiotics, debridement, and wound care remain
essential, newer strategies—such as
antimicrobial-coated materials, negative
pressure wound therapy, and risk prediction
tools—show promise. Moving forward,
prevention must focus on evidence-based
protocols, improved diagnostics, and responsible
antimicrobial use. Integrating innovations like
anti-biofilm therapies and precision medicine
may further reduce SSI incidence and improve
surgical outcomes globally.
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