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Surgical Site Infection (SSI) Rates Among Patients Who Underwent Mastectomy After theIntroduction of SSI Prevention Policies

Author(s): Diana VilarCompte , MD, MSc; Rodrigo RoldnMarn , MD; Carlos RoblesVidal ,MD; Patricia Volkow , MDSource: Infection Control and Hospital Epidemiology, Vol. 27, No. 8 (August 2006), pp. 829-834Published by: The University of Chicago Presson behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/506395.

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i n f e c t i o n co n t r o l a nd h o s p i t a l e p i de m i o l o g y a u g u s t 2 00 6 , v o l . 2 7 , n o . 8

o r i g i n a l a r t i c l e

Surgical Site Infection (SSI) Rates Among Patients Who UnderwentMastectomy After the Introduction of SSI Prevention Policies

Diana Vilar-Compte, MD, MSc; Rodrigo Roldan-Marn, MD; Carlos Robles-Vidal, MD; Patricia Volkow, MD

objective. To describe the results of an intervention program to reduce the rate of surgical site infection (SSI) in the breast tumor

department of a referral teaching hospital for patients with cancer.

methods. Preventive measures introduced in the Breast Tumor Department of the study hospital included the following: starting in

July 2000, use of sterile technique for wound care; starting in 2001, use of closed antireflux silicone evacuation systems, use of perioperative

antimicrobial prophylaxis, provision of feedback to surgeons, and remodeling of the ambulatory wound care clinic. We conducted surveillance

of all patients who underwent mastectomy between February 1 and December 31, 2001, and the SSI rate was calculated. A case-control

analysis was performed for risk factors known to be associated with SSI. Results were compared with the data from 2000.

results. The study included data on 385 surgeries. SSIs were registered in 52 (13.7%) of these 385, which was a rate 58.6% less thanthe 2000 infection rate (33.1%). Risk factors associated with SSI included concomitant chemotherapy and radiation therapy (OR, 3.6 [95%

confidence interval {CI}, 1.9-7.1]), surgery performed during an evening shift (OR, 1.9 [95% CI, 1.1-3.6]), and insertion of a second

drainage tube during the late postoperative period (OR, 2.8 [95% CI, 1.4-5.7]). The mean number ( SD) of postoperative visits to the

outpatient wound care clinic was reduced from in 2000 to in 2001 ( , Students ttest). The mean number of11.6 7.1 9.2 4.4 P! .001

days that the evacuation systems were used was reduced from 19.0 to 16.0 days ( , Studentst test).Pp .001

conclusions. Continuous wound surveillance, along with feedback to surgeons, use of closed antireflux evacuation systems, and

standardized practices in wound and drainage-tube care, decreased by 58.6% the rate of SSI in a breast surgical department with high rates

of infection.

Infect Control Hosp Epidemiol2006; 27:829-834

From the Department of Infectious Diseases (D.V.-M., R.R.-M., P.V.) and the Breast Tumor Department (C.R.-V.), Instituto Nacional de Cancerologa,

Mexico City, Mexico. (Present affiliation: Dermatology Department, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, Mexico [R.R.-M.].)

Received November 4, 2004; accepted August 31, 2005; electronically published July 20, 2006.

2006 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2006/2708-0007$15.00.

Surgical site infections (SSIs) remain one of the most com-

mon causes of morbidity in the surgical patient, despite ad-

vances in surgical practice and antibiotic prophylaxis. Theaverage cost of a surgical wound infection has proven difficult

to estimate and varies depending on the type of surgical pro-

cedure, but hospital costs alone may be over US$2500.00.1-3

The entire economic burden of SSIs is rarely taken into ac-

count, as the majority of wound infections are not diagnosed

until after hospital discharge4,5; the cost to the patient in

prescription charges, visits to the hospital, loss of earnings,

and reduced quality of life are largely underestimated.2,3

Mastectomies have traditionally been considered clean sur-

gical procedures; the majority of studies suggest that the in-

fection rate in clean surgery is 5% or less.6-8 According to the

National Nosocomial Infections Surveillance System, the SSIrate for mastectomies during the past decade ranged between

2.07% and 3.9%7; however, other series have reported higher

rates of infection.9-12

In 2000, the Department of Infectious Diseases and the

Breast Tumor Department at our institution (Instituto Na-

cional de Cancerologa, Mexico City, Mexico) began an active

surveillance program for SSIs that included direct observation

from patient admission to surgery and until the last surgicalfollow-up visit at the outpatient clinic. We identified high

rates of SSI (33.0% of cases) for all types of mastectomies,

and we identified the following risk factors: receipt of con-

comitant chemotherapy and radiation therapy (odds ratio

[OR], 2.3 [95% confidence interval {CI}, 1.2-4.3]; ),Pp .01

obesity (OR, 2.3 [95% CI, 1.2-4.6]; ), radical surgeryPp .01

(OR, 3.1 [95% CI, 1.1-8.6]; ), placement of a surgicalPp .03

drainage tube for 19 days or longer (OR, 2.9 [95% CI, 1.5-

4.6]; ), and insertion of a second drain during thePp .002

late postoperative period (OR, 3.7 [95% CI, 1.8-7.8]; Pp

).12 We also detected an outbreak of Pseudomonas aeru-.002

ginosaSSI,13 as well as poor compliance with infection controlpractices and inappropriate wound management at the out-patient Wound Clinic. As a routine procedure, drainage tubeswere disconnected from the system, washed with tap water,dried, and reconnected to proximal drainage tubes insertedin patients. The evacuation system used polyvinyl chloride

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8 3 0 i n f ec t i on c o nt r o l an d h o sp i t al e p i de m i ol o g y a u g u st 2 0 06 , v o l . 2 7, n o . 8

tabl e 1. Chronology of Surgical Site Infection Control Measures Introduced at the Breast

Tumor Department of the Study Hospital in 2000 and 2001

July 2000

Introduction of sterile technique for wound care, and introduction of sterile surgical

equipment for wound and drainage tube manipulation

January 2001

Introduction of a new drainage tube system, partially silicone with round tubes (Hemovac)June 2001

Introduction of explicit stop orders for antibiotic therapy after surgery, which was

frequently prescribed for 7-10 days. Only perioperative antibiotic prophylaxis was

recommended as a standard.

Introduction of a closed, antireflux, silicone evacuation system with flat tubes (Biovac)

Individual and confidential reporting to surgeons of cases of SSIs and flap necrosis

August 2001

Remodeling of the wound-care area to establish physical barriers between patients and to

provide air conditioning

(PVC) tubes connected to a plastic reservoir with no anti-

reflux system (Drenovac; Equipo e Instumental Medico).Doctors and nurses did not wear sterile gloves for woundcare nor when handling medical supplies (gauze, clamps, andother supplies were not sterile)12; also, 2-3 patients were eval-uated simultaneously in a 20-m2 room that had no physical

barriers between patients and had no air conditioning, whichfavored high temperatures in the area.With the aim of decreasing the rate of SSI after mastectomy,

the following sequenced prevention measures were intro-duced: starting in July 2000, use of sterile technique for

wound care; and starting in 2001, use of closed, antireflux,silicone evacuation systems, use of perioperative antimicro-bial prophylaxis, provision of feedback to surgeons, and re-modeling of the ambulatory wound care clinic to establishphysical barriers between patients and to provide air con-ditioning. Table 1 gives a detailed description of the inter-ventions. This article describes the effect of introducing pre-ventive measures in our Breast Tumor Department, which

had high rates of wound complications. We also discuss ourexperience with continuous surveillance for SSIs and use of

standard sterile procedure for wound and drainage-tube care.

m e t h o d s

Background and Interventions

Between February 1, 2001, and December 31, 2001, all breastsurgeries for cancer performed at the Instituto Nacional deCancerologia were registered. This is a 150-bed, national re-ferral teaching hospital for adult patients with cancer, wheremore than 3,000 surgeries are performed annually. Mastec-

tomies represent more than 10% of all procedures performed

at the institution.

Patients Management and Surveillance

Patients were operated on by the same surgical team andmanaged according to the standard protocol of care; follow-

up included daily medical-chart review, microbiology reports,

and rounds at the patients bedside. After discharge from the

hospital, one physician who was part of the study team con-

ducted direct observation along with the surgeon once or

twice per week, until the last surgical follow-up visit at the

outpatient clinic. Data on the appearance of the wound and

the amount and characteristics of material drained from thewound were collected at each visit on a standardized form.

All patients were followed up for at least 30 days, as previously

described for the year 2000.12 A sample for culture was ob-

tained if infection was suspected because of pain or tender-

ness, localized swelling, redness or heat, purulent drainage

from a superficial or deep incision, fever (temperature, 38C

or higher), or suspicion of an infected wound by the surgeon.

SSI was classified according to the Centers for Disease Control

and Prevention definitions for surgical infection.14

Statistical Analysis

Data collected were introduced into a database (with Paradox9 software; Corel). Patient variables studied included age, body

mass index, duration of hospitalization (preoperative and post-

operative hospital stay), type of mastectomy undergone, history

of smoking (past or current, and if current, whether the patient

had avoided smoking in the 72 hours prior to surgery), pres-

ence of diabetes mellitus, presence of hypertension, previous

receipt of chemotherapy and radiation therapy, American So-

ciety of Anesthesiologists physical status (ASA) score, surgical

shift during which surgery had been performed, prophylactic

and postoperative antibiotic therapy received, receipt of im-

mediate breast reconstruction, and occurrence of other wound

complications, such as flap necrosis, dehiscence, epidermolysis,

and hematoma or seroma formation.We also conducted case-control analysis to verify whether

the data for the patient and operation were similar to those

reported in 2000. Case patients were defined as those with

SSI, and control subjects were patients who underwent a



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fig ur e 1. Monthly rates of surgical site infection (SSI) among

patients who underwent mastectomy at the study hospital, 2000-2001.

mastectomy who were free of infection by day 30 after surgery.

Case and control patients were all selected from the samepopulation (ie, patients who underwent mastectomy in 2001).

For analysis, the number of SSIs per 100 surgeries wascalculated. The frequencies of hematomas, seromas, epider-molysis, and dehiscence were also calculated. The Students

t test, the Mann-WhitneyUtest, and the x2

test for propor-tions were used for analysis (with Stata software for Windows;Stata), as appropriate. To test the association between theoccurrence of SSI and possible risk factors, we estimated oddsratios and 95% confidence intervals (with Epi Info 6 software;

Centers for Disease Control and Prevention). A Pvalue of!.05 was considered statistically significant. Results were com-pared with results for 2000.

r e s u l t s

During the 11-month surveillance period, 385 patients who

had undergone mastectomy were monitored, and 379 (98.4%)

completed the follow-up. Fifty-two surgical infections wereregistered: 40 (76.9%) were superficial incisional infections

and 12 (23.1%) were deep incisional infections. The median

time from surgery to SSI diagnosis was 25.0 days (range, 6-

58 days). Monthly rates of wound infection for 2000 and

2001 are shown in Figure 1.Forty-eight patients developed 1 SSI, and 2 patients de-

veloped 2 wound infections. Cultures were performed for 42

infections (80.7%). The bacteria most frequently isolated

from infected wounds were as follows: Staphylococcus aureus

(6 infections),Klebsiellaspecies (6),E. cloacae(5),Citrobacter

species (4), S. epidermidis (3), Pseudomonas aeruginosa(2),Serratia species (2), and Escherichia coli(2). Other bacteria

were isolated from 6 infections, and cultures were negativefor pathogens in 6 infections. Bacteria isolated from the in-

fected wounds differed little from the bacteria isolated before

the study, except forP. aeruginosa, which was more common

during the previous year (2000, comparison group), when anoutbreak was detected.13 Klebsiella species were more com-

monly isolated in the present series.

The tumor, node, and metastasis (TNM) stages for the 385

patients at the time of surgery were as follows: in situ stage,

4 patients (1.03%); stage I, 19 patients (4.9%); stage IIA, 69

patients (17.9%); stage IIB, 67 patients (17.4%); stage IIIA,65 patients (16.9%); stage IIIB, 44 patients (11.4%), and stage

IV, 20 patients (5.2%). These proportions were similar to the

TNM stages described for the previous year (2000). Two pa-tients had Paget disease diagnosed, and 1 patient had phyl-

lodes diagnosed. Ninety-four patients (24.4%) had a biopsy

performed at another institution and an unavailable pathol-ogy report; thus, TNM staging was incomplete at the time

of surgery.

The mean age ( SD) of case patients was 53.3 1.9

years, and that of control patients was years (P,50.3 0.6not significant). Diabetes mellitus, receipt of neoadjuvant

chemotherapy, immediate breast reconstruction, receipt ofantibiotic prophylaxis, ASA score, duration of surgery, andduration of hospital stay were not associated with infection.Variables shown to be associated with infection were as fol-

lows: preoperative chemotherapy and radiation therapy (OR,3.6 [95% CI, 1.9-7.2]; ), surgery performed duringP!.001

the afternoon or evening shift (OR, 1.9 [95% CI, 1.1-3.6];), and need for reinsertion of a drainage tube duringPp .03

the late postoperative period (ie, 2-3 weeks after surgery) (OR,2.8 [95% CI, 1.3-5.7]; ). Results of univariate analysisPp .01are shown in Table 2.

The mean duration of surgery (SD) was 148.8 6.07minutes for case patients and minutes for non-143.6 4.9infected patients (P, not significant). The mean duration ofhospital stay for case patients was days and that3.3 1.18for control patients was days (P, not significant);3.4 0.98

these findings are very similar to those of previous studies.

In addition to SSI, we monitored other wound-relatedcomplications. Epidemolysis occurred in 19.5% of patients,flap necrosis occurred in 18.2%, dehiscence occurred in10.1%, seromas occurred in 20.8%, and hematomas occurredin 2.1%. Rates of these complications were similar to thoseobserved for the study performed in 2000, except for epi-dermolysis, which decreased from 37.4% of patients to 19.5%.

Data on drainage tube type, duration of drainage tubeplacement, and average number of visits to the outpatient

wound care clinic were compared with the results of the studyperformed in 2000.12 In 2001, the mean time (SD) that adrainage tube remained in place was days, com-16.0 6.56pared with days in 2000 ( , Students t19.0 8.57 Pp .001test). Similarly, the mean number of visits (SD) to theoutpatient wound care clinic was reduced from 11.6 7.1visits in 2000 to in 2001 ( , Studentsttest).9.2 4.4 P!.001Savings related to direct costs of ambulatory wound care wereapproximately US$8,500.00 for 9 months. We did not findsignificant differences in the wound infection rate betweendrainage tube types; however, seromas were less common in

patients with the silicone evacuation system with flat tubes(Biovac; Biometrix). Details about the duration of placement



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tabl e 2. Risk Factor Analysis for Surgical Site Infection According to the Variables Studied (Univariate

Analysis).

Variable

Case group

(np 52)

Control group

(np 327) OR (95% CI) P

Age, mean years SD 53.3 1.86 50.3 0.63 NS

Duration of hospitalization, mean days SD

Preoperative stay 0.98 0.7 1.05 0.02 NSPostoperative stay 2.5 0.14 2.2 0.4 NS

Obesity 14 (26.9) 77 (23.5) 1.2 (0.6-2.4) NS

Diabetes mellitus 7 (13.4) 28 (8.5) 1.7 (0.6-4.4) NS

Hypertension 11 (21.1) 43 (13.1) 1.7 (0.8-3.9) NS

No previous treatment 15 (28.9) 155 (47.4) 1

Preoperative chemotherapy 3 (5.7) 61 (18.6) 0.5 (0.1-1.9) NS

Preoperative chemotherapy and RTa 34 (65.4) 111 (34.0) 3.6 (1.9-7.1) !.001

Duration of surgery of 1180 minb 4 (9.7) 11 (3.4) 2.5 (0.6-9.3) NS

Immediate breast reconstruction 11 (21.1) 54 (16.5) 1.4 (0.7-2.6) NS

Performance of surgery during an evening shift 33 (63.4) 156 (47.7) 1.9 (1.1-3.6) .03

Adequate perioperative antimicrobial prophylaxis 39 (75) 222 (67.8) 0.8 (0.4-1.8) NS

Unnecessary postoperative antibiotic therapyc 25 (48.1) 130 (40.0) 1.4 (0.7-2.6) NS

Second drainage tube placedd 16 (30.7) 45 (13.7) 2.8 (1.4-5.7) .001

note. Data are no. (%) of patients, unless indicated otherwise. NS, not significant.a Concomitant chemotherapy and radiation treatment (RT).b The 75th percentile of the duration of surgery in this cohort.c Use of antimicrobial treatment without infection.d Insertion of an additional drainage tube after surgery because of seroma or hematoma.

tabl e 3. Comparison of the 3 Surgical Drainage Tube Systems

Used at the Study Hospital, 2000-2001

Year, drainage

tube system

No. of

patients

Duration of

drainage tube

placement, days No. (%) of

patients who

developed

seromas

Patients

with SSI

Patients

without SSI

Year 2000Drenovac 230 24.3 16.3 55 (25.6)

Year 2001

Hemovac 209 21 15.2 50 (24)

Biovac 136 17 16 22 (16.2)a

Drenovac 36 23 15.3 8 (22.2)

a The difference in the rate of seroma formation between drainage tube systems

was statistically significant (x2 test, 19.4; ). Data on seroma formationP! .001

were compared between the 2 silicone-tube evacuation systems (Biovac and

Hemovac), and patients using the Hemovac system were found to have an

increased risk of seroma (OR, 5.03 [95% CI, 2.2-11.9]; ).P! .001

and the types of drainage tube used are given in Table 3,along with data on infections and seroma formation for the

drainage tube types.

d i s c u s s i o n

Surveillance of SSIs is costly in human resources and time.

Surveillance of postoperative patients has become a difficulttask with changes in surgical practice, such as shortened du-ration of postoperative stay, greater numbers of outpatientprocedures, and the increased use of laparoscopic surgery,but there is no doubt that surveillance of SSIs has been shownto be a powerful prevention tool if data are collected, ana-lyzed, and used appropriately.15

The prospective surveillance program for SSIs at the BreastTumor Department of our institution allowed us to char-

acterize the frequency of and the risk factors associated withSSI among patients who underwent mastectomy in 2000.12

Starting in July 2000, we introduced sequenced preventivemeasures (Table 1) and observed the effects of these measuresby means of the same surveillance method (ie, direct obser-vation) at the outpatient clinic, in conjunction with the sur-geons. All patients were followed up for at least 30 days, andno changes were observed in the intensity of surveillance orthe variables studied. As shown in Figure 1, the preventiveintervention program decreased the rate of SSI; this decreaseoccurred gradually and was greater during the second half of

2001. Overall, the number of SSIs decreased by more than50% from 2000 to 2001.

Several surveillance methods with various degrees of sen-

sitivity have been reviewed for detection of infected wounds,16,17

but the most precise and reliable method for SSI surveillance

is one that includes examination of the wound and gatheringof information from medical records (ie, reading of the surgicalnotes and culture results). An SSI surveillance program mustbe sufficiently sensitive to identify cases of wound infection

diagnosed after patient hospital discharge.18

The number of SSIs observed during 2000 was clearlyhigher than the reported rate.7,9-11 Mastectomy is classified asa clean procedure; thus, SSI rates should not be higher than



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5%,7 but in studies that have exclusively included patients

with cancer, the rate of infection does tend to be higher.9-11

In patients with advanced stage of cancer, wound compli-cations are even more frequent.12,19-20 In our series, 45.7% ofpatients had an advanced stage of cancer, so more-radicalprocedures with concomitant chemotherapy and radiation

treatment were more common, which probably contributedto a higher rate of wound complications, because chemo-therapy and radiation treatment were strongly associated withSSI (OR, 3.6 [95% CI, 1.9-7.1]).

Determining which of the intervention measures intro-

duced had a greater effect on the decrease of SSIs is difficult,but at least 3 of the strategies were demonstrated to be ef-ficacious. Surveillance for SSI with provision of feedback tosurgeons is a powerful prevention tool15 and has been shownto decrease the incidence of surgical infections in variousstudies.21-23 The latter finding is probably related to the factthat surgeons are more aware of the best surgical techniqueand perioperative patient care.7

As shown in Table 1, we modified the practices for woundand drainage-tube care. In July 2000, as a result of the outbreak

investigation, sterile technique for wound and drainage tubecare was introduced. Later, in January 2001, evacuation systemswere also changed. As reported previously,12 the drainage sys-tems used had PVC tubes, which were frequently convertedto open drainage tubes 10-14 days after surgery. It was also afrequent practice to disconnect tube drains from the reservoir,clean them with tap water to remove fibrin clots, and reattachthem to the evacuation system, which practices are clearly in-appropriate. PVC tubes are also more rigid and may increasedamage to tissues. Guidelines have strongly recommended that

an evacuation system be used only if necessary, and, if used,

it should always be a closed system.24 A radical change in theuse of closed, silicone evacuation systems helped to improveinfection control practices and decreased SSI rates. As shownin Table 3, use of a closed, antireflux, silicone evacuation systemwith flat tubes (Biovac) also diminished the rate of seromaformation ( ). Use of sterile technique for wound andP!.001drainage-tube care during the postoperative period should bestrongly encouraged, because the drainage tube breaks the skinbarrier and constitutes a bridge between the external environ-

ment and the patients tissue.In June 2001, in accordance with best practices for per-

ioperative antibiotic prophylaxis, we decided that patientswho had undergone mastectomy should receive antibioticprophylaxis for no more than 24 hours. As a routine pro-cedure, surgeons chose to continue prophylaxis until alldrainage tubes were removed, despite the fact that evidencedoes not support this practice.25 In mid-2001, explicit stoporders were given, and continuous monitoring of antibioticprescription practices was instituted.

Inappropriate surgical antimicrobial prophylaxis continues

to be a major problem in most hospitals. Inappropriate useof antimicrobial agents not only adds to the cost of medicalcare, but it also increases selective pressure for bacterial re-

sistance in healthcare facilities.15 According to Burke,26 cost

savings and improved infection control rates have been shownto accrue with appropriate use of surgical antimicrobial pro-phylaxis. In our series, in 2000, the cost of unnecessary an-tibiotics per patient was approximately US$20.82; in the sameperiod in 2001, this cost diminished to US$4.47. For the

group of all patients, net cost savings realized by eliminationof unnecessary antibiotic therapy was US$5000.00.The risk factors found to be associated with SSI in 2001

were similar to those reported for the previous year, duringwhich variables related to use of drainage tubes and concom-

itant chemotherapy and radiation treatment were associatedwith SSI. In the 2001 series, the hospital shift during whichsurgery was performed was also studied as a possible riskfactor for SSI. As shown in Table 2, performance of surgeryduring an evening shift increased the risk of infection bynearly 2-fold. This finding could be related to less supervisionby staff surgeons and senior residents. In the literature, arelationship has been reported between greater expertise and

occurrence of fewer wound complications.27,28

In summary, the prospective surveillance program at the

Breast Tumor Department of our institution and the estab-lishment of preventive measures decreased the SSI rate by58.6% in 2001. The program also improved infection controland antibiotic prescription practices and reduced the cost ofmedical care. The 58.6% reduction in the SSI rate observedduring 2001 was maintained throughout 2002.

Address reprint requests to Diana Vilar-Compte, MD, MSc, Departamento

de Infectologa, Instituto Nacional de Cancerologa (INCan), Av. San Fer-

nando 22, Col. Seccion XVI, Mexico City, 14080 Mexico (diana_vilar@

yahoo.com.mx).

Presented in part: 4th Panamerican Meeting Association on Infection Con-trol and Hospital Epidemiology in Cancun, Mexico, November 2002.

acknowledgment

In August 2002, GlaxoSmithKline Foundation (Mexico) gave this research

an award for Best Original Clinical Research Project submitted to the XIII

Premio Nacional de Investigacion de la Fundacion GlaxoSmithKline.

r e f e r e n c e s

1. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ.

The impact of surgical-site infections following orthopedic surgery at a

community hospital and a university hospital: adverse quality of life,

excess length of stay, and extra cost. Infect Control Hosp Epidemiol2002;23:183-189.

2. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming

on the incidence of wound infection after clean surgery: a randomised

controlled trial. Lancet2001; 358:876-880.

3. Reilly J, Twaddle S, McIntosh J, Kean L. An economic analysis of surgical

wound infection. J Hosp Infect2001; 49:245-249.

4. Letrilliart L, Guiguet M, Hanslik T, Flahault A. Postdischarge nosocomial

infections in primary care.Infect Control Hosp Epidemiol2001; 22:493-498.

5. Vilar-Compte D, Mohar A, Sandoval S, De la Rosa M, Gordillo P, Volkow

P. Surgical site infections at the National Cancer Institute in Mexico: a

case-control study. Am J Infect Control2000; 28:14-20.



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