New Methods to Preventing Surgical Site Infections

Erin Sherer, Ed.D, PA-C, RD

AASPA President Elect


Article originally printed in Sutureline: Sep/Oct 2017 pg. 11


Preventing surgical site infections (SSIs) is a key consideration for providers caring for patients who have undergone surgery. But while almost 300,000 SSIs occur annually in the United States (Richter, 2017), research indicates that, in many instances, these SSIs may be preventable.


Despite knowledge of and best efforts to prevent SSIs, there are many risk factors that may contribute to their prevalence. The list begins with whether or not the surgery is elective or emergency. Other considerations include a patient’s history of alcoholism, recent steroid use, malignancies, radiotherapy, or surgery involving the gastrointestinal tract (Athanasiou, Spartalis, & Spartalis, 2017).


Just this year, the Centers for Disease Control published a guide with recommendations to prevent SSIs (Berrios-Torres et al. 2017). The most current recommendations for preventing SSIs include having patients shower or bathe their entire body with soap prior to surgery; providing a higher percentage of inspired oxygen for patients who are intubated; administering intravenous antibiotics during procedures; keeping patients warm during surgery; maintaining blood glucose levels below 200mg/dL perioperatively; and limiting antibiotic use after a procedure when there is no clear benefit (Berrios-Torres et al. 2017).


Previous practices included irrigation for prevention of SSIs, but more recent research calls this strategy into question. In particular, a 2017 systematic literature review indicated that there is little benefit to using antibiotic irrigation to prevent SSIs, and that while the use of prophylactic incisional wound irrigation with an aqueous providone-iodone solution may be considered, the quality of evidence to support this is low (de Jonge et al., 2017).


In contrast to the potential challenges associated with irrigation techniques, other research in this area has instead focused on prophylactic use of negative pressure wound therapy (NPWT). While NPWT is often used to manage wound infections, it may also play a role in preventing them. According to Lewis et al. (2014), placing a negative pressure wound vacuum over a closed laparotomy incision reduced the risk of infection by 28% in obese patients and by 25% in morbidly obese patients. Another study indicated similar findings when NPWT was applied to sternotomy incisions (Grauhan et al., 2013). The authors found that NPWT applied to clean, closed incisions for the first 6 to 7 postoperative days significantly reduced the incidence of wound infection after median sternotomy in high-risk obese patients. More recently, a trial involving 50 patients who had undergone open abdominal surgeries found that the use of NPWT reduced the rate of SSIs at 30 days to 8 percent (versus 32 percent for patients who were given only a standard dressing) (O’learly et al., 2017). The authors of this study also suggested this could be a useful strategy for closed wounds as well.


Other data suggests that vaccines could also be part of the answer to preventing SSIs. A study published in 2017 by Mohamed et al. indicated exactly that when identifying some success in preventing staphylococcus aureus SSIs. The authors suggest a prophylactic vaccine would “ideally provide protective immunity at the time of the surgical incision to prevent initiation and progression of the infection” (p. 212). While there is no vaccine currently in use, the authors are optimistic and indicated that “promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI” (p. 212).


While the most pressing concern associated with SSIs is their status as an unwanted patient complication, the cost of caring for SSIs ranks as an important consideration as well. In particular, SSIs can pose a unique cost burden due to surprising and prolonged hospitalizations and readmissions, as well as ancillary and additional procedures and nursing care (Berrios-Torres, 2017). Implementing these prevention strategies may help reduce patient discomfort and could help lessen the financial burden associated with SSI treatment. While it is clear that more randomized clinical trials need to be done in this area, advances in SSI treatment may be available in the near future that will allow practitioners to provide even better care to their patients.

 

References:

  1. Athanasiou, A. N., Spartalis, M., & Spartalis, E. (2017). Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds After Abdominal Operations: What We Really Know?. Annals of Surgery.
  2. Berríos-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R., ... & Dellinger, E. P. (2017). Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA surgery.
  3. de Jonge, S. W., Boldingh, Q. J., Solomkin, J. S., Allegranzi, B., Egger, M., Dellinger, E. P., & Boermeester, M. A. (2017). Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surgical Infections, 18(4), 508-519.
  4. Grauhan, O., Navasardyan, A., Hofmann, M., Müller, P., Stein, J., & Hetzer, R. (2013). Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. The Journal of thoracic and cardiovascular surgery, 145(5), 1387-1392.
  5. Lewis, L. S., Convery, P. A., Bolac, C. S., Valea, F. A., Lowery, W. J., & Havrilesky, L. J. (2014). Cost of care using prophylactic negative pressure wound vacuum on closed laparotomy incisions. Gynecologic oncology, 132(3), 684-689.
  6. Mohamed, N., Wang, M. Y., Le Huec, J. C., Liljenqvist, U., Scully, I. L., Baber, J., & Anderson, A. S. (2017). Vaccine development to prevent Staphylococcus aureus surgical‐site infections. British Journal of Surgery, 104(2).
  7. O’leary, D. P., Peirce, C., Anglim, B., Burton, M., Concannon, E., Carter, M., & Coffey, J. C. (2017). Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial: The PICO Trial. Annals of surgery, 265(6), 1082-1086.
  8. Richter, G. (2017). Cut and dry insights to prevent surgical site infections. Retrieved from:   https://www.pennmedicine.org/news/news-blog/2017/august/cut-and-dry-insights-to-prevent-surgical-site-infections