Fourth, we selected scientific research cases of suspected SSI to assess agreement about the diagnosis of SSI. However, SSI is suspected in only a small proportion of patients after surgery. Our data on agreement about SSI diagnosis would not apply to an actual series of surgical patients. Fifth, in some countries we did not reach the ten expected surgeons for participation. This lower than expected number of participants could have lead to a less precise analysis. Finally, participants in each country were contacted by European leaders in the field of SSI surveillance and prevention. This recruitment method may have lead to the selection of participants working in universities or high-level hospitals and, therefore, to overestimation of agreement in diagnosing SSI.

In conclusion, among ICPs and surgeons evaluating case-vignettes of possible SSI, considerable disagreement in SSI diagnosis occurred both between and within countries. This finding supports the need for caution when using SSI rates for benchmarking or public reporting. Nevertheless, SSI surveillance and feedback remain critical for SSI prevention, and must be encouraged despite intrinsic limitations. Rather than stopping SSI surveillance because of uncertain reliability, our results support regular evaluations of SSI diagnosis accuracy, with case-vignettes probably constituting a valuable educational tool. Supporting Information Figure S1 Example of a case-vignette developed for the study. (DOC) Click here for additional data file.(127K, doc) Table S1 Characteristics of the 186 study participants from 10 European countries.

(DOC) Click here for additional data file.(52K, doc) Table S2 Characteristics of the 20 real patients used to develop the case-vignettes. (DOC) Click here for additional data file.(62K, doc) Acknowledgments We thank P Nataf, MD, Bichat-Claude Bernard University Hospital, Paris; Philippe Despins, MD, University Hospital, Nantes; Jean-Pierre Marmuse, MD, Bichat-Claude Bernard University Hospital; Philippe Massin, MD, Bichat-Claude Bernard University Hospital; Baptiste Roux, PharmD, Fast4 Company, Paris, and all the European 186 participants who scored the vignettes: Finland Infection control physicians. Outi Lyytikainen, Helsinki University Central Hospital; Bodil Eriksen-Neuman, Vaasa central hospital; Kaisa Huotari, Peijas hospital; Maija Liisa Rummukainen, Jyv?skyl? central hospital;Veli-Jukka Anttila, Helsinki University Central Hospital; Peter Klemets, Porvoo hospital; Pekka Suomalainen, South Carelia Central Hospital; Nabil Karah, University Hospital of North – Norway; Arvola Pertti, Tampere University Hospital; Kirsi GSK-3 Skogberg, Jorvi hospital. Surgeons.