The effect of performance feedback on

wound infection rate in abdominal

hysterectomy
J. F. Garca Rodrguez, DM,a A. Rivera Trobo, MD,b M. V. Lorenzo Garca, MD,c M. J. Carballo Martnez, MD,b
C. Parada Millan, MD,b M. Calaza Vazquez, MD,b J. Ferro Rodrguez, MD,b and J. M. Perez-Mendana, DMb
Ferrol, A Coruna, Spain

Background: In many hospitals, infection of the surgical wound is the most common nosocomial infection. Its presence implies
patient morbidity, a mortality risk, and an increase in procedure costs because of prolonged hospitalization.
Objectives: Our objective was to ascertain the effect of an infection control program, using performance feedback, on wound
infection (WI) rate in abdominal hysterectomy.
Methods: All patients undergoing abdominal hysterectomy in our center (Hospital A. Marcide, Ferrol, Spain) between 1999 and 2004
were prospectively followed up to determine the WI rate. A complete set of parameters, including age, underlying illnesses, cancer,
diabetes mellitus, immunosuppressive therapy, albumin, American Society of Anesthesiologists preoperative assessment score
(ASA) risk, days in hospital presurgery, date of surgery, hygiene and perioperative antimicrobial prophylaxis, type of surgical operation, duration of surgery, surgeon, and WI, were collected in each case. After data collection for 1999 concluded, we communicated
surgical WI rates to surgeons every year. A logistic regression analysis was performed to compare WI rates with those observed in 1999.
Results: A total of 980 females was enrolled in the prospective surveillance: mean age, 50.7 6 10.7 years. Cases included 25.8%
cancer, 4.9% diabetes, 0.5% immunosuppressive therapy, 26.6% ASA 1, 58.4% ASA 2, 13.9% ASA 3. In 9 patients, emergency surgery was performed and, in 971 patients, surgery was scheduled: Total abdominal hysterectomy, 878; subtotal abdominal hysterectomy, 65; Wertheim-Meigs, 37. The factors associated with WI were albumin (OR, 0.97; 95% CI: 0.94-0.99) and antimicrobial
prophylaxis (OR, 0.08; 95% CI: 0.02-0.32). The mean values for albumin and the number of patients with antimicrobial prophylaxis fluctuated from year to year. The WI rate improved from 10.7% (95% CI: 5.8-15.6) in 1999 to 6% (243.9%) in 2004.
Conclusion: Performance feedback of surgical wound infection rates to individual surgeons reduces these rates. (Am J Infect
Control 2006;34:182-7.)

In many hospitals, infection of the surgical wound is

the most common nosocomial infection. Its presence
implies patient morbidity, a mortality risk, and an
increase in procedure costs because of prolonged
hospitalization.
It is a risk inherent in the surgical procedure itself,
varying with patient characteristics, surgical and aseptic technique, and perioperative antibiotic prophylaxis.
The risk factors leading to surgical wound infection are
well-known.1-3 Although it is often impossible to correct factors that arise from the patient herself (age, cancer, malnutrition, and other) or to achieve optimal
preventive measures, the incorporation of a physician
and a nurse, both properly qualified and motivated,
along with a surveillance and control program, has
From the Infectious Diseases Unit,a Gynecology Service,b and Preventive Medicine Service,c Hospital A. Marcide, A Courna, Spain.
Reprint requests: J. F. Garca, Rodrguez, DM, Infections Disease Unit,
Hospital A. Marcide, Carretera de San Pedro s/n, 15405 Ferrol.
A Coruna, Spain. E-mail: jfgarciar@medynet.com.
0196-6553/$32.00
Copyright 2006 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2005.09.011

182

proved that 32% of nosocomial infections can be

prevented.4
To attempt to reduce the infection risk in the surgical
wound, the approach must involve knowledge of the
characteristics of each treating center, followed by an
adjustment of the infection rate in accordance with
the risk factors.5,6 Having access to epidemiologic information may permit prior identification of previously
unsuspected risk factors, thereby motivating the surgeon to take preventive measures. Also, communicating the results in the correct fashion to the surgeons
seems to be an important element in this strategy, as
demonstrated by studies in the United States and
some European countries,7-9 although this type of
study has not been published in Spain. The objective
of our study is to ascertain the effect of an infection
control program on the wound infection rate in abdominal hysterectomies, using a strategy of periodically communicating the results to the surgeon.

METHODS
A prospective study of the surgical wound infection
rate (WI) in all patients undergoing abdominal hysterectomy in our hospital (Hospital A. Marcide, Ferrol,
Spain) between the years 1999 and 2004 was

Rodrguez et al

undertaken. Those cases in which patients had active

infection of the operative site (pelvic inflammatory disease, abscesses) were excluded. Two hours prior to
transferring the patient to the operating theater, the surgical field was prepared by shaving and the application
of povidone-iodine (Betadine; Purdue Pharma, Stanford, CT) and then protected with a sterile drape. In operating theatre and anesthetized, the patient underwent
another disinfection of the operative field and meticulous vaginal cleansing with povidone-iodine (Betadine).
The approved antibiotic prophylaxis protocol in our
hospital during this period was 2 g cefazolin intravenously half an hour before surgery in patients with cancer, obesity, or other significant comorbidity. In cases
of allergy to the betalactamics, a dose of gentamycin
and metronidazole was administered. No changes in
methods of prevention of infection were introduced
over the course of the study nor were the recommended
antibiotic treatment protocols modified.
Following a set protocol, data were obtained for each
patient including variables in Table 1, underlying illness, immunosuppressive treatment, date of surgery,
preoperative hygiene, indication and protocol of antibiotic prophylaxis, and presence of WI up to 30 days
postsurgery. WI has been defined according to the Centers for Disease Control and Prevention (CDC) classification3: Superficial incisional WI (infection involves
only skin or subcutaneous tissue of the incision and
at least 1 of the following: (1) purulent drainage; (2) organisms isolated from an aseptically obtained culture
of fluid or tissue from the superficial incision; (3) at
least 1 of the following signs or symptoms of infection:
pain or tenderness, localized swelling, redness, or heat
and superficial incision is deliberately opened by surgeon, unless incision is culture negative; (4) diagnosis
of superficial incisional WI by the surgeon or attending
physician); deep incisional WI (infection involves deep
soft tissues of the incision, eg, fascial and muscle layers
and at least 1 of the following: (1) purulent drainage; (2)
a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least
1 of the following signs or symptoms: fever .38
C,
localized pain, or tenderness, unless site is culture negative; (3) an abscess or other evidence of infection
involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination; (4) diagnosis of a deep incisional
WI by the surgeon or attending physician); or organ/
space WI (infection involves any part of the anatomy,
eg, organs or spaces, other than the incision, which
was opened or manipulated during the operation, and
at least 1 of the following: (1) purulent drainage from a
drain that is placed through a stab wound into the organ/space; (2) organisms isolated from an aseptically
obtained culture of fluid or tissue in the organ/space;

May 2006

183

Table 1. Variables included in the multivariate analysis

Age
Cancer
Diabetes mellitus
Albumin
ASA risk
Days of preoperative hospitalization
Year of surgery
Scheduled surgery
Emergency surgery
Type of operation
Duration of operation
Surgeon
Antibiotic prophylaxis
Wound infection

(3) an abscess or other evidence of infection involving

the organ/space that is found on direct examination,
during reoperation, or by histopathologic or radiologic
examination; (4) diagnosis of an organ/space WI by
the surgeon or attending physician). All patients
were followed in the outpatient Gynaecology department, (gynaecologic exploration), 30 days after hospital discharge.
Classification as a case of WI was by consensus between a doctor from the infectious disease unit, the gynecologist, and the nurse responsible for dressing the
wound. Once the data for 1999 had been collected,
the surgeons were advised yearly of the incidence of
WI in their service and for each individual surgeon,
in writing and in general clinical sessions, in a coded,
confidential manner. A descriptive study of the variables was carried out, analyzing normalcy by means
of the Kolmogorov Smirnov test. The x2 test was used
to analyze qualitative variables, with Student t test for
the comparison of 2 means in variables of normal distribution, the Mann-Whitney test for variables without
normal distribution, and analysis of variance in multiple mean comparisons. A multiple stepwise logistic regression analysis of the variables specified in Table 1
was performed to analyze annual changes in the incidence of WI compared with baseline (year 1999). We
use the SPSS (SPSS Inc, Chicago, IL) statistical package.
The level of statistical significance was set at P , .05.

RESULTS
A total of 980 females was enrolled in the prospective surveillance. The average age was 50.7 6 10.7
years (range, 21-90 years) and varied between 48.6 6
9.3 years in the year 2000 and 52.7 6 11.2 years in
the year 2001 and was lower in patients with WI,
48.1 6 9 years, compared with 50.9 6 10.8 years in
patients with no WI (P , .05).
Two hundred fifty-three (25.8%) patients were
cancer cases: 534 (54.5%) were myoma cases, 113

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Rodrguez et al

Vol. 34 No. 4

Table 2. Outcomes for surgeons with more than 20 surgical operations*

Yearsy
Surgeon
1
2
3
5
7
9
10
11
12
13
15
17
18
20
22
30
33

1999

2000

2001

2002

2003

2004

Total

Patients with prophylaxis,y

n (%)

1
26
7
12
4
9
12
20
8
21
0
13
10
0
0
0
0

15
8
13
16
4
11
6
10
16
26
8
8
11
0
0
0
0

17
12
3
11
4
14
8
10
6
28
2
17
15
7
0
8
0

19
8
8
0
1
5
10
11
0
26
8
6
9
32
9
21
0

0
5
5
0
5
7
7
17
0
20
4
7
18
22
24
29
13

3
2
6
0
5
5
0
3
0
28
9
3
12
19
18
6
23

55
61
42
39
23
51
43
71
30
149
31
54
75
80
51
64
36

14 (25.5)
29 (47.5)
5 (11.9)
10 (25.6)
13 (56.5)
8 (15.7)
15 (34.9)
39 (54.9)
4 (13.3)
84 (56.4)
7 (22.6)
9 (16.7)
13 (17.3)
15 (18.8)
7 (13.7)
15 (23.4)
7 (19.4)

Wound infection,y
n (%)
2
3
3
6
1
2
4
6
5
9
8
3
4
6
6
4
3

(3.6)
(4.9)
(7.1)
(15.4)
(4.3)
(3.9)
(9.3)
(8.5)
(16.7)
(6)
(25.6)
(5.6)
(5.3)
(7.5)
(11.8)
(6.3)
(8.3)

Surgical operations by year, patients with antimicrobial prophylaxis, and number of surgical wound infections.
P , .001.

(11.5%) had glandular hyperplasia, 43 (4.4%) benign

ovarian tumor, and 37 others had benign diseases.
Forty-eight patients (4.9%) had diabetes mellitus, and
5 (0.5%) received immunosuppressive therapy with
corticosteroids. Two hundred sixty-one patients
(26.6%) were ASA risk 1, 572 (58.4%) ASA risk 2, 136
(13.9%) ASA risk 3, and 11 (1.1%) ASA risk 4. The
mean for days of preoperative stay was 2.56 6 3.1
days (range, 1-28), varying between 3.1 6 3.3 days in
the year 1999 and 2.3 6 2.3 days in the year 2003;
there was no significant difference between patients
with and without WI. The number of abdominal hysterectomy patients per year ranged between 150 in the
years 1999 and 2004 and 183 in 2003. Nine (0.9%)
patients had emergency surgery, and, in 971 patients,
surgery was scheduled: 871 (88.9%) in the morning
and 100 (10.2%) in the afternoon. There were no differences in the incidence of emergency surgery in
the years studied nor in ASA risk frequencies 3 and 4;
afternoon surgery was more frequent in the years
2000 (24.1%) and 2001 (19.1%) than in 1999 (12%)
or 2002 (6.9%), with none at all in 2003 and 2004.
The types of surgical operations were total abdominal hysterectomy, 878 (89.6%) (with bilateral
adnexectomy in 478 [54.4%]; bilateral adnexectomy,
appendicectomy, and omentectomy in 58 [6.6%]; double adnexectomy and external iliac lymphadenectomy
in 55 [6.3%]; unilateral adnexectomy in 31 [3.5%]; unilateral adnexectomy, appendicectomy, and omentectomy in 5 [0.6%]; ovarian cyst removal in 13 [1.5%],
and total simple in 238 [27.1%]); subtotal hysterectomy, 65 (7.4%) (with bilateral adnexectomy in 45
[69.2%]; unilateral adnexectomy in 3 [4.6%], and

ovarian cyst removal in 1 [1.5%]); and a WertheimMeigs operation in 37 (4.2%). The frequency of total
hysterectomy fluctuated between 83.3% in 1999 and
94.4% in 2001, and the frequency of subtotal hysterectomy varied between 11.1% in 2000 and 3.5% in 2002
(P , .05). There were no differences between the types
of surgical operation in the WI rates.
The mean duration of surgery was 79.9 6 29.2 minutes for total abdominal hysterectomy and ranged between 85.4 6 33.1 minutes in 1999 and 74.5 6 22.2
in 2003; it was 82.5 6 27.9 minutes for subtotal hysterectomy, ranging from 65.8 6 8 minutes in 2001 to 95.8 6
47.2 minutes in 2002; for the Wertheim-Meigs operation, it was 183.2 6 25.1 minutes and varied between
206.7 6 30.5 minutes in 2001 and 162 6 2.7 minutes
in 2002. There were no significant differences in the
duration of surgery between patients with and without
WI. The duration was greater in patients with perioperative antimicrobial prophylaxis: 102.4 6 45.5 versus
75.8 6 25.3 minutes, respectively (P , .001).
We placed closed drainage in 114 (11.6%) patients
and open drainage in 4 (0.4%). The use of drainage
was more frequent in prolonged surgery (132.2 6
50.8 vs 77.4 6 26.1 minutes, respectively) but was
not associated with any increase in the rate of infection. The number of patients who received antimicrobial prophylaxis was higher among those who had
drainage than among those who did not (80.5% vs
23.7%, respectively).
The number of surgical procedures performed each
year by the surgeons, the characteristics of patients operated, the number of patients receiving perioperative
antimicrobial prophylaxis, and the WI rates by surgeon

Rodrguez et al

Fig 1. Evolution of antimicrobial prophylaxis and

wound surgical infection rates.
varied from individual to individual (Table 2). The surgeons who did less than 50 interventions operated
less frequently on patients with cancer (21% vs 27.7%,
respectively, P 5 .03), displayed more incidence of
WI (11.5% vs 6.3%, respectively, P 5 .01), and less
use of antibiotic prophylaxis (24.5% of the patients
vs 32.8%, respectively, P 5 .01) compared with the surgeons who operated more. The incidence of WI in the
surgeons who performed few operations was not modified significantly during the period of study nor was
the use of antibiotic prophylaxis, except for greater
use in the year 2001 (P 5 .02). In the group of surgeons
with more of 50 interventions, the incidence was
smaller, it was not modified significantly during the
study, and the use of antibiotic prophylaxis was smaller
in 2002 (19.2% of the patients vs 40% in 1999 and
43.4% in 2004).
The infection rate in patients operated on by surgery
residents was no greater than that for patients operated
on by staff surgeons (7.9% vs 7.7%, respectively), the
duration of the procedures was shorter (71.1 6 19.2
vs 88.1 6 37.9 minutes, respectively), patients presented with cancer less frequently (13.8% vs. 29.7%,
respectively), and patients received prophylaxis less
frequently (18.8% vs 34.3%, respectively) (P , .05).
Seventy-six patients (7.8%) presented with WI. In
the multivariate model, the factors associated with surgical WI were albumin (OR, 0.97; 95% CI: 0.94-0.99)
and antimicrobial prophylaxis (OR, 0.08; 95% CI:
0.02-0.32). Out of 299 patients who had received antimicrobial prophylaxis, 7 (2.3%) of them were infected,
and, out of 681 who had not received antimicrobial
prophylaxis, 69 (10.1%) were infected (P , .001). The
mean values for albumin and the number of patients
receiving perioperative antimicrobial prophylaxis varied from year to year (Fig 1).
According to our services protocol, antimicrobial
prophylaxis was indicated in 301 (30.7%) patients
and was prescribed in 262 (87%); it was administered
correctly in 244 (93.1%) patients. Out of 679 patients

May 2006

185

Fig 2. Evolution of prescribed antimicrobial

prophylaxis when not indicated and wound surgical
infection rates.
with no indication for prophylaxis, it was prescribed
in 37 (5.4%), and this irregularity was greatest in
2001 (Fig 2). In 39 patients, antimicrobial prophylaxis
was indicated but was not prescribed. The frequency
of prophylaxis indicated but not prescribed varied
from year to year; the frequency was highest in 2002
(Fig 3) when, out of 12 patients who did not receive
prophylaxis, 4 (33.3%) of them were infected.
The surgical wound infection rate improved from
10.7% (95% CI: 5.8-15.6) in the year 1999, reaching
6% (243.9%) in 2004. The incidence was lower in
2001 and increased slightly in 2002. These differences
correlate with the number of patients who received
prophylaxis and, specifically, to a higher frequency of
prophylaxis prescribed without indication in 2001
and a higher frequency of prophylaxis not prescribed
in spite of being necessary in 2002 (Figs 2 and 3).
The WI site was superficial in 36 (47.4%) patients,
deep in 16 (21.1%), and in the resected organ cavity
in 24 (31.6%). In 57 cases in which a culture was taken,
the infection was mainly polymicrobial, and the most
frequently found pathogens were Staphylococcus
aureus, Gardnerella vaginalis, Escherichia coli, Peptostreptococcus species, and Prevotella species.
Out of 76 patients with WI, 8 needed a second operation because of this complication. In 45 of these patients, an abscess was drained, and, in 6 patients, an
infected hematoma was drained. The arithmetical
mean of postoperative days of hospitalization was
11.6 6 4.36 days in patients who had WI versus 8.1
6 2.3 days in patients who had no infection (P , .001).

DISCUSSION
Our study, adjusted for the variables that were analyzed, shows that the surveillance and control program
of infection of the surgical wound in abdominal hysterectomies, along with periodic communication of the

186

Vol. 34 No. 4

Fig 3. Evolution of nonprescribed antimicrobial

prophylaxis in patients when indicated and wound
surgical rates.
results to the surgeon, contributed to the reduction in
the infection rate, patient morbidity, and days of hospitalization. Other studies, not adjusted for risk factors,
have shown similar results.7 It is difficult to establish
what produces this effect because there are several variables that can have an influence over a period of time.
In our study, the effect may be due to the fact that the
surgeon, being aware of what his percentage of wound
infection is and being able to compare this with the results of other colleagues working in the same service,
becomes more conscious of the problem and more inclined to optimize preventive measures and operative
technique if this is possible.10-12 Medical and nursing
staffs were unchanged during the period of the study,
apart from the incorporation of a surgery resident doctor each year and of nursing staff during holiday periods and the occasional short sick leave. Although the
incidence varied from surgeon to surgeon, and the number of operations they performed varied over the course
of the study, in the adjusted analysis, the variables most
closely associated with infection risk were albumin
values and, above all, antibiotic prophylaxis.
In our study, we did not analyze the presence of vaginosis nor intraoperative blood loss, variables associated with higher infection risk in other studies.13 It is
possible that the presence of vaginosis is more common in the premenopause woman and that intraoperative blood loss is associated with longer operating
time and the placement of drains. The age of the patient, the duration of the operation, and the placement
of drains were not associated with greater wound infection as in other studies. This may possible be due to the
fact that the placement of drains was more frequent in
the longer procedures, and antibiotic prophylaxis was
more widely used in these.1,14,15
Methods of prevention and control of infection remained unchanged during the study period. The nutritional protein status of the patients improved slightly,

Rodrguez et al

but the number of patients receiving antibiotic prophylaxis in the latter years of the study was not significantly greater than the first year; therefore, we
consider that, apart from slight fluctuations in the intervening years, antibiotic prophylaxis is unlikely to
have contributed to the drop in the infection rate
over this period. We assume that the lower incidence
of infection in 2001 was a result of the administration
of antiobiotic prophylaxis to a greater number of
patients, even when there was no indication for this
according to the services protocol. This in turn may
have been due to an attempt to lower the infection
rate on the part of surgeons after the initial results
had been made known. The upturn in the rate in
2002 may be due to a reverse effect: that of not administering prophylaxis in a larger number of patients in
whom it was indicated, in an attempt to correct the
irregularities in the prophylaxis regime detected the
previous year and made known to the surgeons at
the beginning of that year.
Although there are some randomized, prospective,
double-blind studies whose results support the administration of antibiotic prophylaxis in all abdominal hysterectomy cases,16 something also reflected in the latest
guidelines,17,18 it is not routine practice.7,15 The number
of patients who received prophylaxis varied between
the different surgeons, which undoubtedly contributed
to the differences in the incidence of infection.11
The results revealed that only 2.3% of patients who
received antibiotic prophylaxis suffered an infection,
in spite of having more risk factors, compared with a
10.1% infection rate in those who did not receive it.
For this reason, we decided to apply it to all patients
from the first of January 2005. The practice seems
cost-effective, given that the price of 2 g cefazolin is
1.5 euros because patients suffering an infection extended their hospital stay by some 4 days, increasing
the cost of the procedure considerably.19 The potential
reduction in the infection rate and in the number of
postoperative days hospitalization more than offsets
the cost of prophylaxis, and we do not think that this
widespread application of the measure can have any
significant effect on the development of microbial antibiotic resistance because this is clean-contaminated
surgery, with no great microbial load, and the number
of patients is small.
The incidence of surgical wound infection in our patients is within the values reported in other studies, but
the criteria of wound infection used, the characteristics
of the patients operated on, and the percentage of those
who received antibiotic prophylaxis was different.7,8,20
It is possible that our results may not be able to be universally extrapolated. Every center has to be aware of
its own circumstances and develop an appropriate surveillance and control program. However, other studies

Rodrguez et al

support the usefulness of this working methodology

to reduce the incidence of infection of the surgical
wound, and it is a cost-effective process that should
be encouraged.
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