Reducing the risk of surgical site infections

Surgical site infections (SSIs) are now the most frequently reported health care–associated infection (HAI) in the United States. In Australia, infection of the surgical site occurs in approximately 3% of surgical procedures.^1,2

Reported rates of surgical site infections vary according to the surgical procedure; 1–2% for clean surgical procedures (Class 1) and >20% for selective colorectal procedures (Class 3).³

In a selective example, a single centre in Melbourne documented an infection rate associated with hip and knee arthroplasty at approximately 5%.⁴ These SSIs were associated with a significant increased cost for arthroplasty (61% increased cost, p<0.001), including increased length of stay.

The authors indicated that these high costs were unsustainable and that development of effective, evidence-based interventional strategies was strongly warranted.

Measures introduced

In 2006, in an effort to improve surgical outcomes in the United States, the Center for Medicare and Medicaid Services (CMS) introduced the Surgical Care Improvement Project (SCIP). SCIP focused on four ‘core’ measures:

1. Timely and appropriate antimicrobial prophylaxis.
2. Appropriate hair removal.
3. Glycemic control.
4. Normothermia.

Each of these measures had peer evidence-based publications to validate the practice, and institutions that failed to document a high compliance to these four measures (>90%) risked losing 1–2% of governmental reimbursement.

While SCIP was a noble start in an effort to improved surgical outcomes, the data after four years of implementation documented little to no reduction in the rate of surgical site infections.⁵

Moving forward, it was realised that a myriad of intrinsic and extrinsic risk factors have a major impact on the evolution of a surgical site infection and that any effort to reduce risk will require a robust effort, embracing multiple, evidence-based interventions targeting those selective risk factors.⁴

Evidence-based practices

Since 2013, numerous peer publications have documented the benefit of embracing a surgical care bundle across the surgical spectrum. To date, there are 13 documented evidence-based practices that have been vetted (High to 1A clinical evidence) in the surgical peer literature for inclusion into a surgical care bundle; those individual elements and quality of evidence include:^6-9

1. Non-absorbable oral antibiotics and mechanical bowel prep (1A)
2. Normothermia (1A)
3. Weight-based antimicrobial prophylaxis (1A)
4. Antimicrobial (triclosan-coated) sutures (1A)
5. Glycemic control (1A)
6. Chlorhexidine gluconate (2–4%) preadmission shower (High)
7. Supplemental oxygen (1A)
8. 70% alcohol/2% chlorhexidine perioperative skin prep (1A)
9. Glove change prior to fascial and subcuticular closure (High)
10. Separate wound closure tray (High)
11. Smoking cessation (High)
12. Wound edge protector (High)
13. Staphylococcal colonisation (1A).

The 13 evidence-based interventions have a focal impact on either reducing the element of contamination within the surgical wound prior to closure or enhancing the immune processes within the surgical wound bed.

Of course, this does not preclude the emergence of additional evidence-based practice, since, after all, evidence-based medicine is a moving target, but the present 13 represent in 2018 the current wealth of well-designed clinical studies, meta-analysis and national and international guideline recommendations.

The table above is a brief comparison of the four National (CDC), International (WHO), Societal (ACS) and the Wisconsin-based SSI prevention guidelines. For a larger image, click here.

In the past, one of the more controversial interventional elements was the use of antimicrobial (triclosan-coated) sutures. This technology was commercially released in 2002 without the benefit of clinical trial data, making it difficult for surgical practitioners to assess its clinical benefit as a risk reduction intervention.

However, in 2018, there are now multiple mechanistic investigations, clinical trials, meta-analysis and cost-effective studies, documenting the benefit of this technology across the surgical spectrum.^10-14 The validation of this technology’s risk-reduction potential lies in the fact that it is now recommended as an evidence-based intervention in multiple SSI prevention guidelines.^6-9

The way forward

Going forward, the evidence-based surgical care bundle represents the greatest opportunity for improving surgical outcome across all surgical disciples. Unfortunately, embracing the concept of a care bundle without a mechanism in place to measure compliance negates the benefit of even the most robust interventions.¹⁵

In light of recent published studies documenting the rate of surgical site infection among selective Australian patient populations, one can muse on the intrinsic benefit of developing standardised evidence-based surgical care bundles as an effort to thwart the significant personal and fiscal morbidity associated with these serious infections.

While we live in an evidence-based clinical world, we cannot overlook the salient commentary of David Sackett, who is viewed along with Archie Cochrane as one of the ‘fathers of evidence-based medicine’. In 1996, he published a paper in the British Medical Journal entitled, ‘Evidence-based medicine; what it is and what it isn’t’, stating: “The practice of evidence-based medicine means integrating individual clinical expertise with the best external evidence from systematic reviews.”¹⁶

We can never forget the benefit of ‘clinical expertise’ as we move forward in our implementation of an effective evidence-based surgical care bundle.

*Dr Charles E Edmiston, Jr., PhD, CIC, FIDSA, FSHEA, FAPIC is Emeritus Professor of Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin USA.

References

1. Si D, Rajmokan M, Lakhan P, Marquess J, Coulter C and Paterson D. Surgical site infections following coronary artery bypass graft procedures: 10 years of surveillance data. BMC Infect Dis. 2014;14:PMC4061097.
2. Worth LJ, Bull AL, Spelman T, Brett J and Richards M. Diminishing surgical site infections in Australia: Time trends in infection rates, pathogens and antimicrobial resistance using a comprehensive Victorian Surveillance Program, 2002-2013. Infect Control and Hosp Epidemiol. 2015;36 409-416.
3. Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC. National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008. Am J Infect Control 2008;36:609-626.
4. Peel TN, Cheng AC, Liew D, Buising KL, Lisik J, Carroll KA, Choong PFM, Dowsey MM. Direct hospital cost determinants following hip and knee arthroplasty. Arthritic Care and Res 2015;67:782-790.
5. Edmiston CE, Spencer M, Lewis BD, Brown KR, Rossi PJ, Hennen CR, Smith HW, Seabrook GR. Reducing the Risk of Surgical Site Infections: Did We Really Think That SCIP Would Lead Us to the Promise Land? Surgical Infection 2011;12:169-177.
6. World Health Organization. WHO Global Guidelines for the Prevention of Surgical Site Infection. Geneva [Switzerland]: https://www.ncbi.nlm.gov/books/ NBK401132/.
7. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons/Surgical Infection Society Surgical Site Infection Guidelines-2016 update. Surg Infect 2017:18:379-382.
8. Berrios-Torres S, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017JAMA Surg 2017;152:784-791.
9. Edmiston CE, Borlaug G, Davis JP, et al. Wisconsin Division of Public Health Supplemental Guidance for the Prevention of Surgical Site Infection: an evidence-based perspective, January 2017. https://www.dhs.wisconsin.gov /publications/p01715.pdf.
10. Edmiston CE, Goheen MP, Krepel C, Seabrook, GR, Johnson CP, Lewis BD, Brown KR, Towne JB. Bacterial Adherence to Surgical Sutures: Is There a Role for Antibacterial-Coated Sutures in Reducing the Risk of Surgical Site Infections? J Am Coll Surgeons 203:481-489.
11. Edmiston CE, Daoud FC, Leaper D. Is There an Evidence-Based Argument for Embracing an Antimicrobial (Triclosan) Suture Technology for Reducing the Risk of Surgical Site Infections (SSIs): A Meta-Analysis? Surgery 2013;154:89-100.
12. Wang ZX, Jiang CP, Cao Y, Ding YT. Systematic Review and Meta-analysis of trioclosan-coated sutures for the prevention of surgical site infection. British J Surg 2013;100;465-473.
13. Daoud F, Edmiston CE Leaper D. Meta-analysis: Prevention of Surgical Site Infections Following Wound Closure with Triclosan-Coated Sutures: Robustness of New Evidence. Surgical Infections 2014;15:165-181.
14. Leaper DJ, Edmiston CE, Holy CE. Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures. British Journal Surgery 2017;104:e134-e144.
15. Leaper D, Tanner J, Kiernan M, Assadian O, Edmiston CE. Surgical site Infection: Poor Compliance with Guidelines and Care Bundles. In Press: Int J Wound Medicine 2015;12:357-362.
16. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence-based medicine: what it is and what it isn’t. British Med J 1996;312:71-72.