A 62-year-old man comes to the office due to increasing discomfort and bulging at the right groin. He was previously diagnosed with a direct inguinal hernia but had no operative repair. The patient recently had acute bronchitis with an incessant dry cough, which caused the hernia to enlarge. He has had no abdominal pain, nausea, vomiting, or constipation. Medical history includes hypothyroidism, seasonal allergy, and several previous episodes of sinusitis. Medications are levothyroxine and a glucocorticoid nasal spray. The patient smokes a pack of cigarettes daily and drinks alcohol occasionally. Vital signs are within normal limits. BMI is 24 kg/m². Physical examination shows a nontender, easily reducible groin mass. Surgical hernia repair is planned. Which of the following most increases the risk for postoperative wound infection in this patient?

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11ec25c8_d924_1466_bc81_25ce286e438c_MD0003_00 This patient has an enlarging, symptomatic inguinal hernia and is being appropriately considered for surgical repair. Emergency repair is indicated for patients with bowel obstruction, acute incarceration, or hernia strangulation, but otherwise elective repair is usually appropriate. Besides perioperative pulmonary complications, smoking is associated with an increased risk of surgical site infection (SSI). Smoking causes alterations in tissue perfusion, inflammatory response, and collagen synthesis that can promote infection and contribute to poor wound healing. Current smoking (especially smoking on the day of surgery) is associated with greater risk than past smoking, but patients who quit smoking are still at a moderately increased risk compared to those who have never smoked. Smoking cessation interventions prior to elective surgery are recommended, especially if cessation can be achieved at least 4-6 weeks before surgery. (Choice A) Obese patients are at increased risk of SSI, especially related to abdominal procedures (eg, ventral hernia repair). Underweight patients may also be at increased risk, although this risk is more specifically attributable to malnutrition and hypoalbuminemia. This patient has a normal BMI and attributable risk is nominal. (Choice B) Certain comorbid conditions, especially uncontrolled diabetes and peripheral arterial disease, are associated with increased risk of SSI. Hypothyroidism may blunt fever and mask signs of SSI but is not associated with a significant increase in infection risk. (Choice C) Systemic glucocorticoids (eg, prednisone) and other immunosuppressants can increase risk of SSI. However, topical nasal glucocorticoid solutions have limited systemic absorption and do not appreciably increase the risk. (Choice D) Concurrent infection at a remote site is associated with increased risk of SSI, especially for procedures involving insertion of prosthetic material (eg, hernia mesh), but treated/past sinusitis does not increase the risk. Educational objective: Smoking is associated with an increased risk of surgical site infection and poor wound healing. Current smoking is associated with greater risk than past smoking, but patients who quit are still at increased risk. Smoking cessation is recommended prior to elective surgery, especially if cessation can be achieved at least 4-6 weeks before surgery. References: Association between smoking status, preoperative exhaled carbon monoxide levels, and postoperative surgical site infection in patients undergoing elective surgery. (http://www.ncbi.nlm.nih.gov/pubmed/28199450)

A 62-Year-Old Man Comes to the Office Due to Increasing