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Original Investigation
April 12, 2017

Risk Stratification for Surgical Site Infections in Colon Cancer

Author Affiliations
  • 1Division of General and Gastrointestinal Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Surg. Published online April 12, 2017. doi:10.1001/jamasurg.2017.0505
Key Points

Question  How can the risk of surgical site infections be stratified using readily available clinical characteristics?

Findings  In this cohort study, surgical site infection risk was scored and stratified based on the number of high-risk characteristics such as smoking history, alcohol abuse history, type 2 diabetes status, obesity, operation duration more than 140 minutes, or nonlaparoscopic approach. Surgical site infection incidence rose from 2.3% among patients with 0 risk factors to 13.6% among patients with 4 or more risk factors.

Meaning  This scoring method may provide a simple way to use readily available characteristics to stratify patients by surgical site infection risk.

Abstract

Importance  Surgical site infections (SSIs) feature prominently in surgical quality improvement and pay-for-performance measures. Multiple approaches are used to prevent or reduce SSIs, prompted by the heavy toll they take on patients and health care budgets. Surgery for colon cancer is not an exception.

Objective  To identify a risk stratification score based on baseline and operative characteristics.

Design, Setting, and Participants  This retrospective cohort study included all patients treated surgically for colon cancer at Massachusetts General Hospital from 2004 through 2014 (n = 1481).

Main Outcomes and Measures  The incidence of SSI stratified over baseline and perioperative factors was compared and compounded in a risk score.

Results  Among the 1481 participants, 90 (6.1%) had SSI. Median (IQR) age was 66.9 (55.9-78.1) years. Surgical site infection rates were significantly higher among people who smoked (7.4% vs 4.8%; P = .04), people who abused alcohol (10.6% vs 5.7%; P = .04), people with type 2 diabetics (8.8% vs 5.5%; P = .046), and obese patients (11.7% vs 4.0%; P < .001). Surgical site infection rates were also higher among patients with an operation duration longer than 140 minutes (7.5% vs 5.0%; P = .05) and in nonlaparoscopic approaches (clinically significant only, 6.7% vs 4.1%; P = .07). These risk factors were also associated with an increase in SSI rates as a compounded score (P < .001). Patients with 1 or fewer risk factors (n = 427) had an SSI rate of 2.3%, equivalent to a relative risk of 0.4 (95% CI, 0.16-0.57; P < .001); patients with 2 risk factors (n = 445) had a 5.2% SSI rate (relative risk, 0.78; 95% CI, 0.49-1.22; P = .27); patients with 3 factors (n = 384) had a 7.8% SSI rate (relative risk, 1.38; 95% CI, 0.91-2.11; P = .13); and patients with 4 or more risk factors (n = 198) had a 13.6% SSI rate (relative risk, 2.71; 95% CI, 1.77-4.12; P < .001).

Conclusions and Relevance  This SSI risk assessment factor provides a simple tool using readily available characteristics to stratify patients by SSI risk and identify patients at risk during their postoperative admission. Thereby, it can be used to potentially focus frequent monitoring and more aggressive preventive efforts on high-risk patients.

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