title: A narrative review of microbial biofilm in postoperative surgical site infections: clinical presentation and treatment.
abstract: OBJECTIVE
  The global impact of surgical site infections (SSIs) on health-care systems is considerable: many are related to the formation of a microbial biofilm. Biofilm plays a significant role in the pathogenesis of implantable device-related infections and are also important in persistent postoperative skin and soft tissue wound infections.
  
  
  METHODS
  PubMed and OVID databases were searched for relevant articles regarding biofilm-associated infection in surgery, including epidemiology, diagnosis, treatment and management.
  
  
  RESULTS
  Biofilm-associated infections increase the use of health-care resources, prolong length of stay, increase cost of antibiotic therapy, result in additional surgical revisions and extend rehabilitation after discharge from health care. Staphylococcus aureus and Staphylococcus epidermidis are the most common isolates recovered from device-related infections. Early infection occurs within two weeks of implantation and is associated with intraoperative wound contamination; late-onset infections are often occult prolonging recognition by weeks, months and in some cases, years. Biofilm is a physical barrier against antibodies and granulocytic cell populations which may also impede the penetration of antibiotics. The ideal strategy for preventing biofilm-associated SSI is to prevent intraoperative contamination through compliance with effective surgical care bundles. Management of postoperative biofilm-associated infections involves surgical debridement followed by irrigation with antimicrobial agents and removal of infected devices, followed by insertion of antimicrobial adjuncts such as antimicrobial spacers, beads or sutures together with selective therapeutic agents that penetrate the mature biofilm.
  
  
  CONCLUSIONS
  Biofilm-associated infections are a significant source of postoperative morbidity and mortality. Appropriate interventional strategies are warranted to reduce the risk of intraoperative contamination.
  
  
  BACKGROUND
  The authors have no conflicts.
authors.affiliation: Emeritus Professor of Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, US.
authors.forename: C E
authors.initials: CE
authors.lastname: Edmiston
authors.affiliation: Professor of Microbiology, Faculty of Biology, Medicine and Health, The University of Manchester, UK.
authors.forename: A J
authors.initials: AJ
authors.lastname: McBain
authors.affiliation: Visiting Clinical Fellow, Richard Wells Research Centre, University of West London, UK.
authors.forename: M
authors.initials: M
authors.lastname: Kiernan
authors.affiliation: Emeritus Professor of Surgery, University of Newcastle upon Tyne, UK.
authors.forename: D J
authors.initials: DJ
authors.lastname: Leaper
mesh_terms: D000890:Anti-Infective Agents / Q000627:therapeutic use; D018441:Biofilms; D006801:Humans; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000382:microbiology* / Q000628:therapy*; D014945:Wound Healing
chemical_list: D000890:Anti-Infective Agents
keywords: antibiotic recalcitrance; biofilm; device-related infection; surgical site infection