Reducing the risk of surgical site infections in Australia

In May 2019, the Australian Guidelines for the Prevention and Control of Infection in Healthcare were released under the auspices of the Australian Government, National Health and Medical Research Council and Australian Commission on Safety and Quality in Health Care, as an evidence-based pathway for improving patient outcomes in acute care facilities.¹ As stated in the introduction, “The Guidelines provide a nationally accepted approach to infection prevention and control, focusing on core principles and priority areas for action. They provide a basis for healthcare workers and healthcare facilities to develop detailed protocols and processes for infection prevention and control specific to local settings.”

Preventing the risk of surgical site infections

An important component of the guidelines involves surgery and minimising the risks associated with these invasive procedures. As stated in the guidelines, the risk of surgery-related infection is increased under the following scenarios:

• “Endogenous contamination of the wound (e.g. procedures that involve parts of the body with a high concentration of normal flora such as the bowel).
• “Increase the risk of exogenous contamination (e.g. prolonged operations that increase the length of time that tissues are exposed).
• “Diminished efficacy of the host systemic immune response (e.g. diabetes, malnutrition, or immunosuppressive therapy with radiotherapy, chemotherapy or steroids) or local (tissue) immune response (e.g. foreign bodies, damaged tissue or formation of a hematoma).”
   

Selective efforts to minimise the risk of infection in the surgical patient population include:

• “Removing those wound pathogens that normally colonize the skin.
• “Preventing the multiplication of microorganisms at the operative site — for example by using prophylactic antimicrobial therapy.
• “Enhancing the patient’s defenses against infection — for example by minimising tissue damage and maintaining normothermia.
• “Preventing access of microorganisms into the incision postoperatively by use of a wound dressing.”
   

The selective interventional, risk-reduction practices were in part derived from the National Institute for Health and Clinical Excellence (NICE) surgical-site infection guidelines (NICE 2008) and the World Health Organization (WHO) Global Guidelines for the Prevention of Surgical Site Infection (2016). ^2,3

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Improving outcome through evidence-based practices

The SSI prevention interventions are delineated into three separate intervals: perioperative, intraoperative and postoperative SSI prevention strategies.

1. Perioperative considerations: The perioperative components emphasise the role of appropriate hand hygiene and operating room attire. In addition, the guidelines point out that movement in and out of the operating rooms should be kept to a minimum since the OR is under positive air pressure and excessive door opening increases the risk of aerosol contamination which could very well be problematic, especially in device-related procedures.⁴ While the Australian guidelines emphasise the importance of the patient bathing/showering prior to surgery, the guidelines do not endorse the practice of using an antiseptic agent such as chlorhexidine gluconate (CHG). Recent peer literature suggests that by using a standard application strategy, high skin surface concentrations of CHG can be achieved, sufficient to inhibit or kill skin colonising surgical wound pathogens.⁵ Three additional perioperative components include: appropriate antimicrobial prophylaxis prior to wound incision, nasal decolonisation in patients undergoing orthopedic or cardiothoracic surgery and the use of non-absorbable oral antibiotics and mechanical lavage in patients undergoing colorectal surgery.

2. Intraoperative considerations: Appropriate hand (scrub) hygiene, normothermia and supplemental oxygen in selective surgical procedures (i.e. colorectal) are recommended as important risk-reduction strategies. The guidelines do not make any recommendation for antibiotic redosing. However, the decision to redose the patient during surgery should be based upon the half-life of the prophylactic agent. For instance, cefazolin should be dosed every three hours based upon its relatively short half-life. The guidelines do not recommend the instillation of powdered antibiotic into the wound prior to closure, nor do the guidelines recommend the use of routine wound irrigation prior to closure. The decision not to recommend routine irrigation may be viewed in some quarters as controversial since it has often been suggested that “the solution to pollution is dilution”, suggesting that the removal of hematin, wound debris or necrotic tissue prior to closure represents a prudent practice, likely enhancing wound healing by limiting wound contamination at closure.⁶ The guidelines also endorse the use of double-ring wound protectors as an effective SSI risk-reduction strategy.

A significant inclusion in the 2019 Australian guidelines, which mirror current international, governmental and societal recommendations, is the use of antimicrobial (triclosan-coated) sutures for the prevention of surgical site infections.^7-11 This specific inclusion comes from a wealth of evidence-based studies that includes randomised, controlled clinical trials and meta-analysis documenting that use of triclosan coated sutures for fascial and subcuticular closure has a significant clinical and economic impact on SSI risk reduction.^12-15

3. Postoperative considerations: The final section of the Australian guidelines addressing SSI prevention focuses on postoperative practices. The guidelines suggest that surgical practitioners should avoid the routine use of topical antimicrobial agents for surgical wounds, healing by primary intention since evidence-based studies do not view this practice as an effective risk-reduction strategy. The guidelines also endorse the use of a semi-permeable film membrane with or without an absorbent island to manage surgical wounds that are healing by secondary intention. The guidelines do not recommend the routine use of antimicrobial dressings for postoperative wound management, even though there are some studies in the general surgical and orthopaedic literature suggesting that selective silver containing dressings may have an SSI risk-reduction benefit,^16,17 At present, there is no standard of practice for postoperative wound management and the choice of surgical dressing often (if not always) reflects practitioner bias.

Final thoughts on SSI risk reduction

The NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare represents a comprehensive document, encompassing the broad vista of healthcare-associated infections. The SSI prevention strategy section (pages 175–178) represents a small but important component of the guidance document. Many of the recommendations are in direct agreement with other international, governmental or societal guidance documents. Unfortunately, to date, none of the current published guidelines address the concept of the surgical care bundle, which has emerged as a significant risk reduction strategy. Figure 1 documents the current 13 evidence-based risk reduction recommendations validated by peer publications, randomised controlled trials and meta-analysis, reflecting high or 1A clinical evidence.

Surgical site infections are a significant source of patient morbidity and mortality throughout the globe. The recent publication of the NHMRC Australian Guidelines for the Prevention and Control of Infection in Healthcare represents an important step in the global recognition of the role of evidence-based practice to improve patient outcomes throughout the healthcare continuum. Surgical site infections represent a complex subset of HAIs which are influenced by comorbid risk, surgical technique and microbial virulence. To be sure, evidence-based medicine is a moving target and in the years to come we can expect to see the evolution of innovative risk reduction strategies which following clinical evaluation will be embraced by the peer literature and incorporated into future guidelines to improve surgical patient outcomes.

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

Dr Edmiston was provided funding support to generate this article by Johnson & Johnson Medical Pty Ltd.

References

1. Australian Guidelines for the Prevention and Control of Infection in Healthcare, Canberra: National Health and Medical Research Council (2019). www.nhmrc.gov.au.
2. National Institute for Health and Care Excellence: Surgical site infections: prevention and treatment. National Institute for Health and Care Excellence 2008.
3. Leaper DJ, Edmiston CE: WHO: Global Guidelines for the Prevention of Surgical Site Infection. World Health Organization 2016.
4. Parvizi J, Barnes S, Shohat N, Edmiston CE. The Environment of Care: Is It Time to Reassess Microbial Contamination of the Operating Room as a Risk Factor for Surgical Site Infection in Total Joint Arthroplasty.  Am J Infection Control 2017;45:1267-1272.
5. Edmiston CE, Krepel C, Spencer M, Lee CJ, Malinowski M, Brown KR, Rossi PR, Lewis BL, Seabrook GR. Evidence for Preadmission Showering Regimen to Achieve Maximal Antiseptic Skin Surface Concentrations of Chlorhexidine Gluconate, 4% in Surgical Patients. JAMA Surg. 2015;150:1027-332.
6. Edmiston CE, Spencer M, Leaper D. Antiseptic Irrigation as an Effective Interventional Strategy for Reducing the Risk of Surgical Site Infections. Surgical Infection 2018;19:774-780.
7. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection. JAMA Surgery 2017;152:784-791.
8. Edmiston CE, Borlaug, G, Davis, JP, Gould JC, Roskos, M. Wisconsin Division of Public Health Supplemental Guidance for the Prevention of Surgical Site Infections: An Evidence-Based Perspective January 2017. HAI Prevention - Surgical Site Infections, https://www.dhs.wisconsin.gov/hai/ssi-prevention.htm.
9. NICE, National Institute for Health and Care Excellence, Surgical site infections: prevention and treatment NICE guideline [NG125]. https:// www.nice.org.uk/ guidance/ng125.
10. World Health Organization (WHO) Global guidelines on the prevention of surgical site infection. https://www.who.int/infection-prevention/publications/ssi-guidelines/en/
11. Ban KA, Minei KP, Laronga C, Harbrecht BG, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surgeons 2017;224:59-74.
12. 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.
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. De Jonge SW, Atema JJ, Solomkin JL, Boermeester MA. Meta-analysis and trial sequence analysis of triclosan coated sutures for the prevention of surgical site infections. British J Surgery 2017;104:e118-e113.
16. Krieger BR, Davis DM, Sanchez JE, Mateka JJL, Nfonsam VN, Frattini JC, Marcet JE. The use of silver nylon for prevention of surgical site infections following colon and rectal surgery. Dis Colon Rectum 54;1014-1019.
17. Tisosky AJ, Ivoha-Bello O, Demosthenes N, Quimbayo G, Coreanu T, Abdeen A. Use of silver-nylon dressing following total hip and knee arthroplasty decreases the postoperative infection rate. J American Academy Orthop Surg Research Review 2017;1:1-7.

Image credit: ©stock.adobe.com/au/Virojt