Surgical site infections (SSIs) are a significant contributor to postoperative complications, but a study published recently highlights an even greater concern: the co-occurrence of hospital-onset bacteremia and fungemia (HOB) and its staggering clinical and financial costs.
In fact, patients with SSIs are six times more likely to develop bacteremia or fungemia while in the hospital, according to an analysis of SSI admissions at 38 acute care hospitals reported to the National Healthcare Safety Network (NHSN). Kalvin C. Yu, MD, FIDSA, the study’s senior author, said SSI patients with a concurrent HOB incur an additional $28,000 in healthcare costs and remain hospitalized for six additional days compared with those who do not develop these nosocomial infections.
“While SSIs are typically localized to the surgical site, bloodstream infections are more severe and systemic, increasing the risk for sepsis,” said Dr. Yu, the vice president of medical and scientific affairs at Becton Dickinson. These infections increase patient comorbidity, mortality risk, can increase costs as well as the potential for readmission within 30 days.
The impetus for this study came from the CDC’s efforts to develop a quality measure for HOB rates, with the Centers for Medicare & Medicaid Services (CMS) considering it for future hospital quality-reporting programs. Currently, hospitals must report infections including SSIs, central line-associated bloodstream infections (BSIs) and catheter-associated urinary tract infections (UTIs), with reimbursement penalties for poor performance. HOB is the first proposed new metric in this area in 15 years, according to Dr. Yu.
Despite the link between SSIs and HOB, Thomas File Jr., MD, MSc, MACP, FIDSA, FCCP, pointed out that SSIs are only a fraction of total HOB cases. Citing a 2024 study conducted by the CDC, which aimed to determine the sources and preventability of HOB in hospitalized patients, Dr. File explained that only 6% of HOB cases were associated with SSIs. Other sources, like gastrointestinal or endovascular sites, were more likely to be associated with HOB.
Importantly, 40% of the HOB cases associated with SSIs were preventable. “That’s the really important message here,” said Dr. File, who is the chair of the Summa Health Infectious Disease Division and a founder and co-director of the Antimicrobial Stewardship Program at Summa Health, in Akron, Ohio. “By tracking HOB, the CDC identified previously unrecognized nosocomial infections. If 40% of these cases are preventable, we can use these data to refine our prevention strategies, reduce the incidence of SSIs and ultimately improve patient care.”
This potential for improvement underscores the need for stronger infection control measures, particularly in the wake of the setbacks faced during the COVID-19 pandemic.
“When there was a big surge in patients, we saw infection-prevention protocols that we thought were hard-wired just fall apart,” Dr. Yu said. “We should be doubling down on proven strategies like proper preoperative skin sterilization and appropriate intraoperative wound irrigation.”
One debated approach is using broad-spectrum antimicrobial prophylaxis in high-risk operations. Heather Evans, MD, MS, the chief of surgery at the Ralph H. Johnson VA Medical Center, in Charleston, S.C., argued that Dr. Yu’s study corroborates the appropriate use of preoperative prophylaxis antimicrobials, because most of the bacteremias observed were from organisms sensitive to standard prophylaxis regimens, like Enterobacteriaceae.
“At the end of the day, local antibiograms should inform our best practices, adjusting prophylaxis accordingly if resistance patterns emerge,” Dr. Evans said. “We need to recognize the potentially unmodifiable patient or operative risk factors that could contribute to the development of HOB, and we need to think about the implications for surgical decision-making, not just focus on SSI bundle compliance.”
She emphasized that NHSN definitions of SSIs differ from clinical diagnoses of postoperative infections, noting that many surgeons are unfamiliar with NHSN’s concept of “infection present at the time of surgery [PATOS].”
“PATOS is determined by evidence of infection documented in the narrative portion of the operative note or report of surgery,” Dr. Evans said. “If we do not use the language that the NHSN expects, the infection will be attributed to the operation itself rather than the infection necessitating the operation.”
Dr. Yu and his colleagues also found that the hospital-reported rate of all SSIs was 0.15 per 100 admissions. The overall rate of SSI differed depending on the type of surgery, with 70% of all SSIs reported as originating from colorectal surgeries.
This finding aligns with well-established surgical infection risks, as colorectal procedures inherently involve contamination from the GI tract. However, the increased infection rates may also be influenced by patient-specific factors and comorbidities.
However, some clinicians, including Dr. Evans, have raised concerns about the study’s limitations. “While it’s great to see this analysis, it’s hard to extrapolate these findings to the real world,” she said. “The data set lacks details about the hospitals, including whether surgeries were elective or emergent; or patient comorbidities and severity; or illness at time of admission.”
The sources reported no relevant financial disclosures out their employment.
This article is from the April 2025 print issue.