Prevention of Surgical Site Infection

➡️Rationale

Surgical site infections (SSIs) are potential complications associated with any type of surgical procedure. Although SSIs are among the most preventable HAIs. they still represent a significant burden in terms of patient morbidity and mortality and additional costs to health systems and service payers worldwide. Up to 60% of SSIs are preventable using evidence-based guidelines. When not prevented, SSIs can result in a significant increase in postoperative hospital days and many also require reoperation, both during the initial surgical admission and during hospital readmission. For these reasons, the prevention of SSI has received considerable attention from surgeons, infection control professionals and health care authorities.

·   Factors increasing the risk of SSI

Many factors influence surgical wound healing and determine the potential for infection.  These include patient-related (endogenous) and process/procedural-related (exogenous) variables that affect a patient’s risk of developing an SSI. Some variables are obviously not modifiable, such as age and gender. However, other potential factors can be improved to increase the likelihood of a positive surgical outcome, such as nutritional status, high body mass index, tobacco use, correct use of antibiotics and the intraoperative technique. Some other burden identified as diabetes, the absence or >1 hour administration of antibiotic prophylaxis and the type of wound classification (contaminated or dirty) are associated with SSI.

·   Infrastructure requirements

Facilities performing surgery should have the following elements in place:

1.    Trained infection prevention personnel on methods of SSI surveillance and case definitions of SSIs

2.    Education for healthcare partitioners as a surgeon leader or champion who can be a critical partner in changing culture and improving adherence to prevention practices. Regularly provide education to surgeons and perioperative personnel through continuing education activities directed at minimizing perioperative SSI risk through implementation of recommended process measures.

3.    Education of patients and families. Provide education for patients and patients’ families to reduce risk associated with intrinsic patient-related SSI risk factors

·  Preoperative Measures

In most cases, hair removal at the surgical site should be avoided unless it interferes with the operation. If hair removal is necessary, it should be done with clippers or depilatory cream, ideally on the day of surgery and as close to the procedure as possible. Razors should not be used due to the increased risk of surgical site infections.

·  Preoperative surgical antibiotic prophylaxis

Begin administration within 1 hour prior to incision to maximize tissue concentration. Administering an antimicrobial agent <1 hour prior to incision is effective. Two hours are allowed for the administration of vancomycin and fluoroquinolones according to drug bioavailability due to longer infusion times. 

Select appropriate antimicrobial agents based on the surgical procedure, the most common pathogens known to cause SSI for the specific procedure, and published recommendations and adjust dosing based on patient weight. Although it is not recommended to routinely use vancomycin, this agent should be considered in patients who are known to be methicillin resistant staph aureus (MRSA) colonized (including those identified on preoperative screening), particularly if the surgery involves prosthetic material.

·  Combination parenteral and oral antimicrobial agents

Use of combination parenteral and oral antimicrobial agents to reduce the risk of SSI should be considered in any surgical procedure where entry into the colon is possible or likely, as in gynecologic oncology surgery. Mechanical bowel preparation without use of oral antimicrobial agents does not decrease the risk of SSI.

·  Decolonize surgical patients for orthopedic and cardiothoracic procedures.

Decolonization refers to the practice of treating patients with an antimicrobial and/or antiseptic agent to suppress MRSA. The strongest data recommend up to 5 days of intranasal mupirocin (twice daily) and bathing with chlorhexidine gluconate (CHG) (daily).

·   Alcohol-containing preoperative skin preparatory agents in combination with an antiseptic

Alcohol is highly bactericidal and effective for preoperative skin antisepsis, but it does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with CHG or an iodophor. Be aware of the risks of using skin antiseptics in babies, in particular the risk of severe chemical injuries with the use of chlorhexidine (both alcohol-based and aqueous solutions) in preterm babies. If diathermy is to be carried out: Use evaporation to dry antiseptic skin preparations and avoid pooling of alcohol-based preparations. Alcohol is contraindicated for certain procedures due to fire risk, including procedures in which the preparatory agent may pool or not dry (e.g., involving hair). Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.

The most effective antiseptic to combine with alcohol remains unclear; however, data from recent trials favor the use of CHG–alcohol over povidone-iodine–alcohol. CHG- alcohol is the antiseptic of choice for patients with MRSA colonization. In the absence of alcohol, CHG may have advantages over povidone-iodine, including longer residual activity and activity in the presence of blood or serum.

When deciding which antiseptic skin preparation to use, options may include those in annex 1 (table 1).

·   Maintain normothermia (temperature >35.5°C) during the perioperative period for procedures not requiring hypothermia,

Even mild hypothermia can increase SSI rates. Hypothermia may directly impair neutrophil function or impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia. Hypothermia may increase blood loss, leading to wound hematomas or the need for transfusion - both of which can increase SSI rates.

·    Control blood-glucose level during the immediate postoperative period for all patients.

Monitor and maintain postoperative blood-glucose level regardless of diabetes status. Maintain postoperative blood-glucose level between 110 and 150 mg/dL. Increased glucose levels during the operational procedure are associated with higher levels in the postoperative setting.

·  Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety

The World Health Organization (WHO) checklist is a 19- item surgical safety checklist to improve adherence with best practices. Studies demonstrated that use of the WHO checklist led to lower surgical complication rates, including SSI and death.

·   Perform surveillance for SSI.

The surveillance of HAI is one of the core components of an effective IPC program. The primary aim of surveillance is the collection of data on SSI rates in order to obtain a measure of the magnitude of the problem. These data must then be analysed to identify and investigate trends, including a careful interpretation of results. Finally, surveillance data should guide the identification of improvement actions and evaluate the effectiveness of these interventions. In this context, the feedback of SSI rates to relevant stakeholders is important.

Identify high-risk, high-volume operative procedures to be targeted for SSI surveillance based on a risk assessment of patient populations, operative procedures performed, and available SSI surveillance data. Identify, collect, store, and analyze data needed for the surveillance program. Develop a database for storing, managing, and accessing data collected on SSIs. Implement a system for collecting data needed to identify and report SSIs.

·   Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit, and/or surgical ward

a. Perform direct observation audits of hand-hygiene practices among all healthcare personnel with direct patient contact.

b. Evaluate wound care practices.

c. Perform direct observation audits of environmental cleaning practices.

d. Provide feedback and review infection control measures with healthcare personnel in these perioperative care settings.