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Prevention of surgical site infections
WOUND MANAGEMENT
Prevention of surgical site infections
An organ/space SSI involves any part of the body deeper than the fascial or muscle layers that is opened or manipulated during the operative procedure (specific sites listed by the Centers for Disease Control and Prevention1) and the patient has at least one of the following: purulent drainage from a drain that is placed into the organ/space organisms are identified from an aseptically-obtained fluid or tissue in the organ/space by microbiological testing an abscess or other evidence of infection involving the organ/space that is detected clinically or radiologically.1
Katherine Mockford Helen O’Grady
Abstract Surgical site infections (SSI) are a major healthcare burden throughout the world and prevention is paramount in reducing the impact of this common category of healthcare associated infection. SSI may be classified as superficial incisional, deep incisional or organ/space and are caused by both patient and procedural factors. UK guidelines on prevention were published in 2008 and the World Health Organization has recently published guidelines in 2016 which are summarized here.
Incidence The World Health Organization (WHO) has found that up to onethird of patients undergoing a surgical procedure in low and middle income countries are affected by SSI.2 In the UK the cumulative incidence of SSI varies according to the type of surgery. Between April 2011 and March 2016 147 NHS trusts submitted data on 611,700 procedures and the highest incidence of SSI was observed in colorectal surgery (9.8%) and the lowest incidence in hip and knee prosthesis surgery (0.6%).3
Keywords Hospital acquired infection; prevention; surgical site infection; wound sepsis
Definition Surgical site infection (SSI) is defined as an infection occurring within 30 days of surgery (90 if a prosthesis is involved) and can be divided into three categories by location; superficial incisional, deep incisional, and, organ/space SSI.1 A superficial incisional SSI only involves the skin and subcutaneous tissue of the incision and has at least one of the following: purulent drainage from the superficial incision organisms identified through microbiological testing from an aseptically-obtained specimen from the incision superficial incision that has been deliberately opened by a surgeon or designee when the patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema or heat diagnosis of a superficial incisional SSI by the surgeon or designee.1 A deep incisional SSI involves the deep soft tissues of the incision (e.g. fascial and muscle layers) and the patient has at least one of the following: purulent drainage from the deep incision a deep incision that spontaneously dehisces or is deliberately opened or aspirated by a surgeon or designee and organisms are identified through microbiological testing and the patient has at least one of the following signs or symptoms: fever >38 C, localized pain or tenderness an abscess or other evidence of infection involving the deep incision that is detected clinically or radiologically.1
Pathology and pathogenesis The creation of a wound triggers an inflammatory response to begin the healing process. This response includes pre-emptive mobilization of host defences (phagocytes) into the wound to tackle ensuing bacterial contamination. The following four factors are at play to determine whether there will be a continuation of the normal healing process or the development of an SSI: number of bacteria present (infective load) ability of the bacteria to produce an infection (virulence) wound environment
Wound classification4 Class Type I II
III
IV
Katherine Mockford MRCS MD is an ST7 in Surgery at Castle Hill Hospital, Hull, UK. Conflicts of interest: none declared. Helen O’Grady FRCS is a Consultant Colorectal Surgeon at Castle Hill Hospital, Hull, UK. Conflicts of interest: none declared.
SURGERY --:-
Definition
Example
Clean
No entry into viscus or tract CleanHollow viscus opened contaminated but with minimal contaminated spillage
Joint replacement, breast, hernia Cholecystectomy, elective colorectal resection, uncomplicated appendicectomy Contaminated Viscus or tract opened Inadvertent with major enterotomy contaminated spillage or inflammatory process Dirty An active infection is Perforated already present; i.e. diverticular disease gross contamination secondary to pus or perforation, incision through an abscess
Table 1
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
Risk factors
Risk factors for surgical site infections (SSI)2,5 Non-modifiable Infective load
Virulence Wound environment
Wounds are defined as being clean, clean-contaminated, contaminated or dirty based on the site and degree of contamination. Greater contamination within the wound leads to a greater the risk of developing SSI (Table 1). Other risk factors for development of SSI can be divided into non-modifiable and modifiable risk factors (Table 2). Causative organisms are related to the site of surgery (Table 3). The most frequent causative organisms in SSI in the UK have changed over the past 10 years with a steady reduction in Staphylococcus aureus infections since 2006 and increase in SSI caused by Gram negative bacteria. Gram negative bacterial SSI now account for 28% of infections.3
Modifiable
Infective organism
Surgical antibiotic prophylaxis MRSA eradication treatment Infective organism Surgical antibiotic prophylaxis Mechanism of wound High volume centre Anatomical site operated Procedure sterility Technique upon (wound type) Use/type of prosthesis Duration of procedure Wound haematoma
Patient factors American Society of Anaesthesia grade (ASA) 3 Age Immunosuppression Malnutrition Obesity Diabetes Ascites Renal failure Jaundice
Diagnosis and investigations Clinical examination in combination with blood and microbiological testing are the mainstays of diagnosis and investigation. Deep/organ infections may present more insidiously with nonspecific symptoms, failure to progress or postoperative ileus. Radiological imaging maybe required. In the assessment of sepsis appropriate microbiological cultures including blood cultures should be taken prior to starting antibiotics as sterilization of cultures can occur within a short time frame of starting antibiotics, therefore making tailoring antibiotic therapy difficult. The Surviving Sepsis campaign recommends that hospitals screen for sepsis in acutely unwell patients and adhere to performance improving programs (i.e. surviving sepsis campaign care bundles).6 Surveillance can reduce SSI rates from between three and 57%.2
Hyperglycaemia Hypothermia Hypoxia Anaemia Blood transfusion Smoker Nutritional state
Table 2
Prevention ability of the patient to fight infection (patient factors). Viable tissue surrounding an infected wound will display the classic signs of inflammation (rubor, calor, tumour and dolor) due to increased local blood supply, accumulation of tissue oedema and the stimulation of pain receptors.4
The WHO developed guidelines published in November 2016 encompassing their recommendations for the prevention of SSI in the perioperative period and these are summarized in Table 4.2 Recommendations are made with respect to their effect on SSI prevention and therefore should not be extrapolated further than
Surgical site and likely infective wound pathogens3,5 Surgical site
Staphylococcus Coagulase-negative Gram-negative Streptococci Anaerobes Others aureus staphylococci bacilli
Cardiac Neurosurgery Breast Ophthalmic Orthopaedic Vascular Gastroduodenal Biliary Colorectal Head and neck Obstetric and gynaecological Urological Foreign material
D D D D D D
D D D D D D
D D D D
D
D D D
D
D
D D
D
Oropharyngeal anaerobes
D D
D
D
Oropharyngeal anaerobes Enterococci, group B streptococci
D
Table 3
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2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
Summary of the recommendations on preventing surgical site infections from the World Health Organization guidance 20162 Topic Preoperative measures Preoperative bathing Mupirocin ointment for S. aureus infection prevention Screening of ESBL colonization Optimal timing for preoperative surgical antibiotic prophylaxis Mechanical bowel preparation combined with the use of oral antibiotics Hair removal Surgical site preparation Antimicrobial skin sealants (sterile filmforming cyanoacrylate-based sealants) Surgical hand preparation Perioperative/intraoperative measures Enhanced nutritional support (oral or enteral support) Perioperative discontinuation of immunosuppressive agents Perioperative oxygenation Maintaining normal body temperature (normothermia) Use of protocols for perioperative blood glucose control Maintenance of adequate circulating volume control/normovolaemia Drapes and gowns
Wound protector devices Incisional wound irrigation prior to wound closure
Prophylactic negative pressure wound therapy Use of surgical gloves Changing of surgical instruments to a new set of sterile instruments on closure Antimicrobial coated sutures Laminar flow ventilation systems for operating room ventilation Postoperative measures Surgical antibiotic prophylaxis prolongation after the completion of the operation Advanced dressings e.g. alginates, hydrocolloids Antimicrobial prophylaxis in the presence of a drain and optimal timing for drain removal
WHO recommendation
Yes e either with plain soap or antimicrobial Yes e for nasal carriers No recommendation made Should be given prior to the surgical incision (when indicated) Yes e in elective colorectal surgery Should only be removed with a clipper (not shaved) Alcohol based antiseptic solutions based on CHG Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI Either antimicrobial soap and water or a suitable alcohol based handrub Consider for the prevention of SSI in underweight patients undergoing major operations Do not stop immunosuppressive medication for the purpose of SSI prevention Patients with endotracheal intubation should receive an 80% fraction of inspired oxygen intraoperatively and if feasible 2e6 hours postoperatively Warming devices recommended Yes e protocols for intensive perioperative blood glucose control for diabetics and nondiabetics. No recommendation on optimal target glucose levels due to lack of evidence Goal-directed fluid therapy intraoperatively is recommended Recommends either sterile, disposable non-woven or sterile reusable woven drapes and gowns Plastic adhesive incise drapes are not recommended for the purpose of preventing SSI Yes e for clean-contaminated, contaminated and dirty abdominal surgical procedures C No recommendation made for irrigation with saline C Irrigation with aqueous PVP-I solution particularly in clean and clean-contaminated wound should be considered C Antibiotic incisional wound irrigation should not be used Yes e for high risk wounds No recommendation made on double-gloving, change of gloves during the operation or a specific type of glove made No recommendation made Yes e triclosan-coated sutures No e laminar airflow should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery No e antibiotic therapy should not be prolonged beyond the operation No e not recommended Not recommended to prolong antibiotics in the presence of a drain No recommendation given on optimal timing of a drain removal
ESBL (extended spectrum beta-lactamases), CHG (chlorhexidine gluconate), PVP-I (povidone-iodine).
Table 4
SURGERY --:-
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
for this role. The National Institute for Health and Care Excellence (NICE) published the most recent UK guidance in 2008.7
Ensuring good surgical technique is paramount to minimizing complications and this includes adequate incision length, delicate tissue handling and appropriate diathermy use. A metaanalysis has shown no difference between using a scalpel or cutting diathermy for the creation of an incision;9 however, cutting diathermy is not recommended by NICE.7 Antimicrobial impregnated sutures have not only been shown to be clinically effective10 but also associated with significant cost savings11 due to a reduction in complications and are therefore recommended.2 There is no evidence to support the use of topical antiseptics or antimicrobials prior to wound closure.7
Preoperative measures As far as possible all modifiable risk factors need to be addressed before a patient is admitted for surgery (Table 2). Recent guidance has recommended preoperative oral antibiotics combined with mechanical bowel preparation should be used for adult colorectal patients undergoing elective surgery, but mechanical bowel preparation alone has no role in reducing SSI alone. The rationale for preoperative antibiotics in a cleansed bowel is to target the bacterial load of the gastrointestinal load and target such bacteria likely to be causative agents in subsequent SSI development.2 Prior to the patient coming into theatre, the operating staff and the theatre environment should be ‘clean’ in order to minimize bacterial load. The patient is recommended to have a bath or shower prior to surgery and hair removal should be carried out with a clipper rather than by shaving to reduce the potential for small wounds that may harbour bacteria. MRSA eradication should be completed for nasal carriers with mupirocin ointment.7 For the theatre team NICE specifically recommends dedicated theatre wear; staff wearing theatre clothing should keep their movements in and out of the operating area to a minimum and hand jewellery and artificial nails/polish should be removed prior to operations. Intraoperatively, the operative team should wash their hands prior to the first operation with a single use brush or pick and then use antiseptic solution or an alcoholic hand rub.7 Regarding the theatre environment laminar flow ventilation systems have been previously recommended particularly in orthopaedic surgery;7 however, recent studies have shown conflicting arguments.2 Laminar flow has not been specifically recommended by the WHO as no benefit was identified although this was a conditional recommendation based on low quality evidence. The basis of this non superiority may be related to wound hypothermia from the cooling effect of laminar airflow.2
Postoperative measures Ensuring adequate postoperative oxygenation, nutrition, hydration, glycaemic control and tissue perfusion are all important elements in the recovery process. Careful attention should be paid to wound management. An aseptic non-touch technique for dressing changes and sterile saline for wound cleaning up to 48 hours post op should be adopted. Patients may shower safely after 48 hours. For more complex wounds and those healing by secondary intention interactive dressings should be considered and advice from dedicated wound care professionals, including tissue viability teams, should be sought.7
Conclusion Surgical site infections are a common and significant burden on the healthcare system throughout the world. Careful attention to detail at each stage of the perioperative journey should be maintained by all members of the team in order to reduce the risk of such infections occurring. A REFERENCES 1 Surgical site infection event. January 2017. Centers for Disease Control and Prevention, www.cdc.gov/nhsn/pdfs/pscmanual/ 9pscssicurrent.pdf (accessed 28 Mar 2017). 2 Global guidelines on the prevention of surgical site infection. November 2016. World Health Organization, http://www.who.int/ gpsc/ssi-prevention-guidelines/en/ (accessed 28 Mar 2017). 3 Surveillance of surgical site infections in NHS hospitals in England 2015/16. December 2016. Public Health England, https://www. gov.uk/government/publications/surgical-site-infections-ssisurveillance-nhs-hospitals-in-england (accessed 28 Mar 2017). 4 Pathogenesis of SSI. http://www.medscape.org/viewarticle/ 448981_2 (accessed 28 Mar 2017). 5 Mangram A, Horan T, Pearson M, et al. Guideline for the prevention of surgical site infection, 1999. Hospital Infection Control Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250e80. 6 Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2016. March 2017, http:// www.survivingsepsis.org/Guidelines/Pages/default.aspx (accessed 28 Mar 2017). 7 Surgical site infections: prevention and treatment. Updated February 2017. NICE, https://www.nice.org.uk/guidance/CG74/ chapter/1-Guidance (accessed 29 Mar 2017). 8 Park HM, Han SS, Lee EC, et al. Randomized clinical trial of preoperative skin antisepsis with chlorhexidine gluconate or povidoneeiodine. BJS 2017; 104: e145e50.
Intraoperative measures Surgical antibiotic prophylaxis given at induction of anaesthesia is recommended for any surgery apart from clean procedures not involving an implant or prosthesis.7 Antibiotics should be specific and targeted to the likely causative organisms (Table 3) and appropriate for the patient taking account of allergies and comorbidities. The administration of the dose should occur no earlier than 120 minutes prior to the incision being made (WHO). Prolongation of prophylactic antibiotics after the operation is not recommended in the prevention of SSI.2 Skin preparation should be carried out, where possible with chlorhexidine and alcohol based solutions2 although it is important to remember to allow flammable alcohol based skin preparations to evaporate, and avoid pooling and soaking of drapes prior to the use of diathermy. These solutions cause irritation to and dry out mucous membranes, so may not be appropriate depending on the anatomy of the surgical field. In contrast to WHO recommendations, a recent randomized controlled trial of hepatobiliary surgery comparing chlorhexidine with povidone iodine prep has shown no difference in SSI rates.8
SURGERY --:-
4
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
9 Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg 2012; 99: 613e20. 10 De Jonge SW, Atema JJ, Solomkin JS, et al. Meta-analysis and trial sequential analysis of triclosan coated sutures for the
SURGERY --:-
prevention of surgical-site infections. BJS 2017; 104: e118e33. 11 Leaper DJ, Edmiston Jr CE, Holy CE. Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures. BJS 2017; 104: e134e44.
5
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
Prevention of surgical site infections
An organ/space SSI involves any part of the body deeper than the fascial or muscle layers that is opened or manipulated during the operative procedure (specific sites listed by the Centers for Disease Control and Prevention1) and the patient has at least one of the following: purulent drainage from a drain that is placed into the organ/space organisms are identified from an aseptically-obtained fluid or tissue in the organ/space by microbiological testing an abscess or other evidence of infection involving the organ/space that is detected clinically or radiologically.1
Katherine Mockford Helen O’Grady
Abstract Surgical site infections (SSI) are a major healthcare burden throughout the world and prevention is paramount in reducing the impact of this common category of healthcare associated infection. SSI may be classified as superficial incisional, deep incisional or organ/space and are caused by both patient and procedural factors. UK guidelines on prevention were published in 2008 and the World Health Organization has recently published guidelines in 2016 which are summarized here.
Incidence The World Health Organization (WHO) has found that up to onethird of patients undergoing a surgical procedure in low and middle income countries are affected by SSI.2 In the UK the cumulative incidence of SSI varies according to the type of surgery. Between April 2011 and March 2016 147 NHS trusts submitted data on 611,700 procedures and the highest incidence of SSI was observed in colorectal surgery (9.8%) and the lowest incidence in hip and knee prosthesis surgery (0.6%).3
Keywords Hospital acquired infection; prevention; surgical site infection; wound sepsis
Definition Surgical site infection (SSI) is defined as an infection occurring within 30 days of surgery (90 if a prosthesis is involved) and can be divided into three categories by location; superficial incisional, deep incisional, and, organ/space SSI.1 A superficial incisional SSI only involves the skin and subcutaneous tissue of the incision and has at least one of the following: purulent drainage from the superficial incision organisms identified through microbiological testing from an aseptically-obtained specimen from the incision superficial incision that has been deliberately opened by a surgeon or designee when the patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema or heat diagnosis of a superficial incisional SSI by the surgeon or designee.1 A deep incisional SSI involves the deep soft tissues of the incision (e.g. fascial and muscle layers) and the patient has at least one of the following: purulent drainage from the deep incision a deep incision that spontaneously dehisces or is deliberately opened or aspirated by a surgeon or designee and organisms are identified through microbiological testing and the patient has at least one of the following signs or symptoms: fever >38 C, localized pain or tenderness an abscess or other evidence of infection involving the deep incision that is detected clinically or radiologically.1
Pathology and pathogenesis The creation of a wound triggers an inflammatory response to begin the healing process. This response includes pre-emptive mobilization of host defences (phagocytes) into the wound to tackle ensuing bacterial contamination. The following four factors are at play to determine whether there will be a continuation of the normal healing process or the development of an SSI: number of bacteria present (infective load) ability of the bacteria to produce an infection (virulence) wound environment
Wound classification4 Class Type I II
III
IV
Katherine Mockford MRCS MD is an ST7 in Surgery at Castle Hill Hospital, Hull, UK. Conflicts of interest: none declared. Helen O’Grady FRCS is a Consultant Colorectal Surgeon at Castle Hill Hospital, Hull, UK. Conflicts of interest: none declared.
SURGERY --:-
Definition
Example
Clean
No entry into viscus or tract CleanHollow viscus opened contaminated but with minimal contaminated spillage
Joint replacement, breast, hernia Cholecystectomy, elective colorectal resection, uncomplicated appendicectomy Contaminated Viscus or tract opened Inadvertent with major enterotomy contaminated spillage or inflammatory process Dirty An active infection is Perforated already present; i.e. diverticular disease gross contamination secondary to pus or perforation, incision through an abscess
Table 1
1
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
Risk factors
Risk factors for surgical site infections (SSI)2,5 Non-modifiable Infective load
Virulence Wound environment
Wounds are defined as being clean, clean-contaminated, contaminated or dirty based on the site and degree of contamination. Greater contamination within the wound leads to a greater the risk of developing SSI (Table 1). Other risk factors for development of SSI can be divided into non-modifiable and modifiable risk factors (Table 2). Causative organisms are related to the site of surgery (Table 3). The most frequent causative organisms in SSI in the UK have changed over the past 10 years with a steady reduction in Staphylococcus aureus infections since 2006 and increase in SSI caused by Gram negative bacteria. Gram negative bacterial SSI now account for 28% of infections.3
Modifiable
Infective organism
Surgical antibiotic prophylaxis MRSA eradication treatment Infective organism Surgical antibiotic prophylaxis Mechanism of wound High volume centre Anatomical site operated Procedure sterility Technique upon (wound type) Use/type of prosthesis Duration of procedure Wound haematoma
Patient factors American Society of Anaesthesia grade (ASA) 3 Age Immunosuppression Malnutrition Obesity Diabetes Ascites Renal failure Jaundice
Diagnosis and investigations Clinical examination in combination with blood and microbiological testing are the mainstays of diagnosis and investigation. Deep/organ infections may present more insidiously with nonspecific symptoms, failure to progress or postoperative ileus. Radiological imaging maybe required. In the assessment of sepsis appropriate microbiological cultures including blood cultures should be taken prior to starting antibiotics as sterilization of cultures can occur within a short time frame of starting antibiotics, therefore making tailoring antibiotic therapy difficult. The Surviving Sepsis campaign recommends that hospitals screen for sepsis in acutely unwell patients and adhere to performance improving programs (i.e. surviving sepsis campaign care bundles).6 Surveillance can reduce SSI rates from between three and 57%.2
Hyperglycaemia Hypothermia Hypoxia Anaemia Blood transfusion Smoker Nutritional state
Table 2
Prevention ability of the patient to fight infection (patient factors). Viable tissue surrounding an infected wound will display the classic signs of inflammation (rubor, calor, tumour and dolor) due to increased local blood supply, accumulation of tissue oedema and the stimulation of pain receptors.4
The WHO developed guidelines published in November 2016 encompassing their recommendations for the prevention of SSI in the perioperative period and these are summarized in Table 4.2 Recommendations are made with respect to their effect on SSI prevention and therefore should not be extrapolated further than
Surgical site and likely infective wound pathogens3,5 Surgical site
Staphylococcus Coagulase-negative Gram-negative Streptococci Anaerobes Others aureus staphylococci bacilli
Cardiac Neurosurgery Breast Ophthalmic Orthopaedic Vascular Gastroduodenal Biliary Colorectal Head and neck Obstetric and gynaecological Urological Foreign material
D D D D D D
D D D D D D
D D D D
D
D D D
D
D
D D
D
Oropharyngeal anaerobes
D D
D
D
Oropharyngeal anaerobes Enterococci, group B streptococci
D
Table 3
SURGERY --:-
2
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
Summary of the recommendations on preventing surgical site infections from the World Health Organization guidance 20162 Topic Preoperative measures Preoperative bathing Mupirocin ointment for S. aureus infection prevention Screening of ESBL colonization Optimal timing for preoperative surgical antibiotic prophylaxis Mechanical bowel preparation combined with the use of oral antibiotics Hair removal Surgical site preparation Antimicrobial skin sealants (sterile filmforming cyanoacrylate-based sealants) Surgical hand preparation Perioperative/intraoperative measures Enhanced nutritional support (oral or enteral support) Perioperative discontinuation of immunosuppressive agents Perioperative oxygenation Maintaining normal body temperature (normothermia) Use of protocols for perioperative blood glucose control Maintenance of adequate circulating volume control/normovolaemia Drapes and gowns
Wound protector devices Incisional wound irrigation prior to wound closure
Prophylactic negative pressure wound therapy Use of surgical gloves Changing of surgical instruments to a new set of sterile instruments on closure Antimicrobial coated sutures Laminar flow ventilation systems for operating room ventilation Postoperative measures Surgical antibiotic prophylaxis prolongation after the completion of the operation Advanced dressings e.g. alginates, hydrocolloids Antimicrobial prophylaxis in the presence of a drain and optimal timing for drain removal
WHO recommendation
Yes e either with plain soap or antimicrobial Yes e for nasal carriers No recommendation made Should be given prior to the surgical incision (when indicated) Yes e in elective colorectal surgery Should only be removed with a clipper (not shaved) Alcohol based antiseptic solutions based on CHG Antimicrobial sealants should not be used after surgical site skin preparation for the purpose of reducing SSI Either antimicrobial soap and water or a suitable alcohol based handrub Consider for the prevention of SSI in underweight patients undergoing major operations Do not stop immunosuppressive medication for the purpose of SSI prevention Patients with endotracheal intubation should receive an 80% fraction of inspired oxygen intraoperatively and if feasible 2e6 hours postoperatively Warming devices recommended Yes e protocols for intensive perioperative blood glucose control for diabetics and nondiabetics. No recommendation on optimal target glucose levels due to lack of evidence Goal-directed fluid therapy intraoperatively is recommended Recommends either sterile, disposable non-woven or sterile reusable woven drapes and gowns Plastic adhesive incise drapes are not recommended for the purpose of preventing SSI Yes e for clean-contaminated, contaminated and dirty abdominal surgical procedures C No recommendation made for irrigation with saline C Irrigation with aqueous PVP-I solution particularly in clean and clean-contaminated wound should be considered C Antibiotic incisional wound irrigation should not be used Yes e for high risk wounds No recommendation made on double-gloving, change of gloves during the operation or a specific type of glove made No recommendation made Yes e triclosan-coated sutures No e laminar airflow should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery No e antibiotic therapy should not be prolonged beyond the operation No e not recommended Not recommended to prolong antibiotics in the presence of a drain No recommendation given on optimal timing of a drain removal
ESBL (extended spectrum beta-lactamases), CHG (chlorhexidine gluconate), PVP-I (povidone-iodine).
Table 4
SURGERY --:-
3
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
for this role. The National Institute for Health and Care Excellence (NICE) published the most recent UK guidance in 2008.7
Ensuring good surgical technique is paramount to minimizing complications and this includes adequate incision length, delicate tissue handling and appropriate diathermy use. A metaanalysis has shown no difference between using a scalpel or cutting diathermy for the creation of an incision;9 however, cutting diathermy is not recommended by NICE.7 Antimicrobial impregnated sutures have not only been shown to be clinically effective10 but also associated with significant cost savings11 due to a reduction in complications and are therefore recommended.2 There is no evidence to support the use of topical antiseptics or antimicrobials prior to wound closure.7
Preoperative measures As far as possible all modifiable risk factors need to be addressed before a patient is admitted for surgery (Table 2). Recent guidance has recommended preoperative oral antibiotics combined with mechanical bowel preparation should be used for adult colorectal patients undergoing elective surgery, but mechanical bowel preparation alone has no role in reducing SSI alone. The rationale for preoperative antibiotics in a cleansed bowel is to target the bacterial load of the gastrointestinal load and target such bacteria likely to be causative agents in subsequent SSI development.2 Prior to the patient coming into theatre, the operating staff and the theatre environment should be ‘clean’ in order to minimize bacterial load. The patient is recommended to have a bath or shower prior to surgery and hair removal should be carried out with a clipper rather than by shaving to reduce the potential for small wounds that may harbour bacteria. MRSA eradication should be completed for nasal carriers with mupirocin ointment.7 For the theatre team NICE specifically recommends dedicated theatre wear; staff wearing theatre clothing should keep their movements in and out of the operating area to a minimum and hand jewellery and artificial nails/polish should be removed prior to operations. Intraoperatively, the operative team should wash their hands prior to the first operation with a single use brush or pick and then use antiseptic solution or an alcoholic hand rub.7 Regarding the theatre environment laminar flow ventilation systems have been previously recommended particularly in orthopaedic surgery;7 however, recent studies have shown conflicting arguments.2 Laminar flow has not been specifically recommended by the WHO as no benefit was identified although this was a conditional recommendation based on low quality evidence. The basis of this non superiority may be related to wound hypothermia from the cooling effect of laminar airflow.2
Postoperative measures Ensuring adequate postoperative oxygenation, nutrition, hydration, glycaemic control and tissue perfusion are all important elements in the recovery process. Careful attention should be paid to wound management. An aseptic non-touch technique for dressing changes and sterile saline for wound cleaning up to 48 hours post op should be adopted. Patients may shower safely after 48 hours. For more complex wounds and those healing by secondary intention interactive dressings should be considered and advice from dedicated wound care professionals, including tissue viability teams, should be sought.7
Conclusion Surgical site infections are a common and significant burden on the healthcare system throughout the world. Careful attention to detail at each stage of the perioperative journey should be maintained by all members of the team in order to reduce the risk of such infections occurring. A REFERENCES 1 Surgical site infection event. January 2017. Centers for Disease Control and Prevention, www.cdc.gov/nhsn/pdfs/pscmanual/ 9pscssicurrent.pdf (accessed 28 Mar 2017). 2 Global guidelines on the prevention of surgical site infection. November 2016. World Health Organization, http://www.who.int/ gpsc/ssi-prevention-guidelines/en/ (accessed 28 Mar 2017). 3 Surveillance of surgical site infections in NHS hospitals in England 2015/16. December 2016. Public Health England, https://www. gov.uk/government/publications/surgical-site-infections-ssisurveillance-nhs-hospitals-in-england (accessed 28 Mar 2017). 4 Pathogenesis of SSI. http://www.medscape.org/viewarticle/ 448981_2 (accessed 28 Mar 2017). 5 Mangram A, Horan T, Pearson M, et al. Guideline for the prevention of surgical site infection, 1999. Hospital Infection Control Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250e80. 6 Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2016. March 2017, http:// www.survivingsepsis.org/Guidelines/Pages/default.aspx (accessed 28 Mar 2017). 7 Surgical site infections: prevention and treatment. Updated February 2017. NICE, https://www.nice.org.uk/guidance/CG74/ chapter/1-Guidance (accessed 29 Mar 2017). 8 Park HM, Han SS, Lee EC, et al. Randomized clinical trial of preoperative skin antisepsis with chlorhexidine gluconate or povidoneeiodine. BJS 2017; 104: e145e50.
Intraoperative measures Surgical antibiotic prophylaxis given at induction of anaesthesia is recommended for any surgery apart from clean procedures not involving an implant or prosthesis.7 Antibiotics should be specific and targeted to the likely causative organisms (Table 3) and appropriate for the patient taking account of allergies and comorbidities. The administration of the dose should occur no earlier than 120 minutes prior to the incision being made (WHO). Prolongation of prophylactic antibiotics after the operation is not recommended in the prevention of SSI.2 Skin preparation should be carried out, where possible with chlorhexidine and alcohol based solutions2 although it is important to remember to allow flammable alcohol based skin preparations to evaporate, and avoid pooling and soaking of drapes prior to the use of diathermy. These solutions cause irritation to and dry out mucous membranes, so may not be appropriate depending on the anatomy of the surgical field. In contrast to WHO recommendations, a recent randomized controlled trial of hepatobiliary surgery comparing chlorhexidine with povidone iodine prep has shown no difference in SSI rates.8
SURGERY --:-
4
Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012
WOUND MANAGEMENT
9 Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg 2012; 99: 613e20. 10 De Jonge SW, Atema JJ, Solomkin JS, et al. Meta-analysis and trial sequential analysis of triclosan coated sutures for the
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prevention of surgical-site infections. BJS 2017; 104: e118e33. 11 Leaper DJ, Edmiston Jr CE, Holy CE. Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures. BJS 2017; 104: e134e44.
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Please cite this article in press as: Mockford K, O’Grady H, Prevention of surgical site infections, Surgery (2017), http://dx.doi.org/10.1016/ j.mpsur.2017.06.012