Managing Surgical Site Infections

About

➀ Read and Learn

The following course content

Surgical site infections have the highest mortality rate of all healthcare-associated infections, with a mortality rate of 3% (4, 9, 36). Further, surgical site infections are costly for facilities, with an estimated total cost of $3.3 billion dollars and approximately one million extra unnecessary inpatient days for patients (12, 36). It is vital to utilize evidenced-based practice strategies to reduce surgical site infections.  

Introduction   

In my second semester of nursing school, a patient that I took care of as a student nurse had open-heart surgery, and he was on my floor. I was the student nurse assigned to him and got to discharge him that day; everything seemed to go well. He was progressing well, and he and his family were excited he was going home. A few weeks later, I was shadowing in the ICU and was shocked to see my patient from just a few weeks before laying before me on a ventilator and with multiple IV medications. The ICU nurse worked swiftly, and I stood in awe of her ability to monitor the many machines he needed in order to survive. It was eerily quiet in the ICU, and the nurse pulled me aside to let me know that the patient was not going to make it that day and that he would probably pass sometime in the afternoon. I wondered why? What could be causing this man that I had discharged from the hospital just a few weeks ago to now be dying? During a bit of downtime, I finally got the courage to ask the nurse; she then pulled back his gown. His surgical wound was red, inflamed, and weeping with pus. It was packed with layers of gauze and had an odor to it. His surgical site became infected, and he became septic. Due to the sepsis, all his internal organs were shutting down. Despite the broadest and most advanced antibiotics, the damage was done, and this patient would not recover. I then realized how serious surgical site infections could be. The patient died later that day surrounded by his daughter and son.  

Surgical site infections (SSI) are serious and associated with significant morbidity and mortality. A patient who develops an SSI is twice as likely to die as one who does not (11). Patients with surgical site infections have a fivefold increase in the chance of being readmitted to the hospital and are 60% more likely to need ICU care than those who do not develop SSI (11). Preventing surgical site infections is imperative as the number of surgical interventions in the U.S. continues to increase (6).  

Epidemiology

SSIs are defined as an infection that happens in a part of the body where the surgery takes place. The infection must occur at or near the incision within thirty days of the initial procedure or ninety days if there is any prosthetic material implanted during the procedure (7, 19). SSIs can be caused by either endogenous (microorganisms present on the patient’s skin when the surgical incision is made) or exogenous microorganisms (those from an outside environment) (11). The most common causing microorganisms of SSI are gram-positive organisms, like Staphylococcus aureus (11). Gram negative organisms like Escherichia coli are more common causative agents in gastrointestinal tract surgeries. Exogenous sources of microorganisms include things like operating room surfaces, contaminated surgical instruments, personnel, and the air (11). 

SSIs have decreased over the last several years due to a number of evidence-based interventions that health care systems implement for prevention (8). Hospitals that have implemented evidence-based prevention programs have observed a 27% reduction in SSIs (13). Further, SSIs are costly, with each surgical site infection estimated to cost from $11,000 to $25,000 for each patient. That is a projected cost to the United States of $3.2 to $10 billion each year (11).  

Risk Factors for Surgical Site Infections 

There are three main categories for risk factors for developing surgical site infections: patient factors, wound factors, and procedural variables.  

Patient Factors 

There are several modifiable and non-modifiable patient risk factors that increase a patient’s risk of developing a surgical site infection, including very young or very old age, diabetes with increased HA1C and glucose over 200 within 48 hours after surgery, tobacco use, steroid use, compromised immune system, infection or colonization at a remote body site, obesity, poor nutritional status, and length of preoperative hospitalization (11). We will review the most modifiable risk factors and some strategies to assist patients or providers with modification during this module. 

Tobacco Use 

Smoking is a modifiable risk factor for the development of SSIs. Smoking is associated with a significantly increased risk of SSI and additional complications of surgical procedures (26). It is recommended that smokers quit between four and six weeks before elective surgical procedures to reduce pulmonary issues and wound complications (23, 24, 25, 31). It is especially important for procedures that involve the creation of flaps (e.g. flap-based mastectomy reconstruction) due to the importance of tissue oxygenation and complications of wound dehiscence (16, 24, 25, 31). Smokers have higher rates of wound healing complications and SSI. The Centers for Disease Control has some excellent resources for patients to quit smoking.  

Diabetes/Elevated Blood Glucose 

Elevated blood glucose levels are associated with increased risks of SSI, regardless of whether the patient has diabetes or not (11). There is evidence that elevated HA1C is associated with SSI and those diabetic patients should aim for HA1C less than 7% pre-surgery (11). Perioperative and postoperative glucose control is also very important and glucose during surgery and within 48 hours post-procedure should be maintained at less than 200 mg/dL (6).  

Remote Infections/Colonization 

It is important for patients with an active infection to complete treatment for that infection prior to elective surgery (18). For example, a patient has a scheduled knee replacement surgery and is undergoing treatment for impetigo (a skin infection) on their left arm. Ideally, they would complete the treatment for the impetigo prior to the knee replacement in order to avoid a possible SSI. It is particularly important to do this when there is going to be placement of prosthetic material during the procedure, like in the case of the knee replacement.  

There has not been a consensus on the benefit and cost-effectiveness of Staphylococcus aureus screening and decolonization for patients undergoing surgery. Some studies have found a benefit and reduced rates of SSI (32, 33, 35), and others have not found any benefit (17). Therefore, it is recommended that S. aureus screening and decolonization be tailored to clinical circumstances. Some institutions have developed protocols that involve screening and decolonization for high-risk procedures, like cardiothoracic surgery, orthopedic procedures with prosthetic material implanted, and immunocompromised patients (32, 33, 35, 36). The most common decolonization protocols include nasal application of mupirocin 2% ointment twice daily for five days, and chlorhexidine wash daily for five days.  

Wound Factors 

Wound contamination is a huge risk factor for the development of an SSI (11). The surgical team classifies wounds based on the amount of microbial contamination, and this classification can be used as one way to assess the risk of a patient developing a surgical site infection. SSIs happen in about 4% of clean wounds and 35% of grossly contaminated wounds.  

Procedural Risk Factors 

There are several risk factors related to the actual procedure that can affect the risk of an SSI. The risk factors include antimicrobial prophylaxis, surgical scrub; preoperative hair removal; the protocol and choice for skin antiseptic; operating room ventilation; surgical timing, duration, and surgical techniques (11).  

The timing of surgery for a patient can lead to an increased risk of SSI. Sometimes the timing of the surgery (e.g. when during a disease course progression to have surgery versus preplanned versus emergent) can be modifiable, and sometimes, it is not (3). Patients who are undergoing emergent surgery or emergency surgery do have higher rates of SSI; this may be due to issues related to contamination or not being able to address modifiable patient risk factors (e.g., glucose control or smoking status) prior to the surgical procedure (3). Further, if a patient is undergoing treatment for cancer with chemotherapy or radiation, there is an increased risk of SSI. If an elective surgical procedure can be delayed during cancer treatment, this does decrease the risk of SSI (3).  

Infection Prevention Strategies 

There are several important infection prevention strategies to reduce the risk of SSIs. The vital pieces of SSI prevention include timely administration of preoperative antibiotics, surgical techniques, and interventions to reduce potential contamination from a healthcare worker. It is imperative to bundle these interventions for a reduction in SSI (3). 

Surgical Attire and Barrier Devices 

The American College of Surgeons has clear guidance for surgical attire (5). 

1. Surgical scrubs should not be worn for patient encounters out of the operating room (OR). 
2. OR scrubs should not be worn outside of the hospital. If worn inside of the hospital and outside of the OR, they should be covered by a clean cover or lab coat. 
3. Attire worn during a contaminated or dirty case should be changed before the next case, even if they are not visibly soiled. 
4. Any OR attire that is visibly soiled should be changed as soon as possible. 
5. During all procedures, the nose, mouth, and hair must be covered.  
6. Head and neck jewelry should be removed or covered.  
7. Double gloving is recommended to protect the surgeon. 
8. Masks, caps, gowns, drapes, and shoe covers are utilized to protect healthcare personnel from exposure to blood and body fluids. 

Hand Hygiene 

General hand hygiene practices should be followed by all surgical team members. For example, anesthesiologists and certified registered nurse anesthetists should clean their hands prior to medication administration in order to reduce microbial content on the hands and then stopcocks (21). 

That healthcare personnel participating in the surgery or entering the sterile field (e.g., surgeon, scrub, or surgical assistants) must also perform surgical hand hygiene. Surgical hand hygiene consists of cleaning the hands, forearms, and under the nails with an antiseptic solution (either antiseptic soap and water or alcohol-based hand rub designed for surgical hand hygiene (15).  

False fingernails, long fingernails, hand, and wrist jewelry should be removed prior to surgical hand hygiene (15). 

Skin Antisepsis 

It is very important to reduce microbial content or load on the skin prior to the surgical procedure which is completed by skin antisepsis of the patient’s skin. Skin antisepsis must be performed prior to any surgical procedure. Ideal agents for skin antisepsis should significantly reduce the bacterial load on the skin, including a broad-spectrum antimicrobial agent, be fast-acting and continue to reduce microbial load after application or have a sustained effect (11). For clean and clean-contaminated procedures, research shows that chlorohexidine is a preferred agent (14, 27, 29). Each agent has a recommended application per the manufacturer.  

Hair Removal 

Hair removal prior to surgery should be avoided due to an increased risk of SSI. The highest risk of SSI is when surgery is performed after hair removal with a razor. Razors cause small micro-abrasions in the skin and increase the microbial load on the skin. Therefore, hair removal should not be completed with a razor. If hair removal is necessary prior to a surgical procedure, it should be done with clippers or depilatory creams with clippers as the preference due to the lowest risk of SSI (10, 20, 22). 

Antimicrobial Prophylaxis    

Antimicrobial prophylaxis is a short course of antibiotics administered just prior to a surgical procedure to reduce the antimicrobial load in the body. Antimicrobial prophylaxis must be administered prior to class one and two wounds because it assumed that for classes three and four, patients are on antibiotics. Agents are chosen based on the type of surgical procedure. Antimicrobial prophylaxis must be administered at an appropriate time in related to the surgical procedure: 30-60 minutes prior to the first incision or one to two hours for antibiotics that have a long administration time (e.g., vancomycin), should be re-dosed if it the procedure has been delayed for more than one hour after the completion of the agent, during surgery serum levels of the antibiotic must be maintained, and antibiotics should be discontinued within 24 hours of the procedure (11).  

Preoperative Showering 

It is recommended by the Centers for Disease Control and Prevention that patients reduce the microbial load on their skin by showering preoperatively with an antiseptic solution. Showering with chlorhexidine gluconate has been shown to reduce microbial load on the skin by nine times. The Association of Operating Room Nurses recommends that patients undergoing a clean procedure shower twice with chlorhexidine gluconate 4%, including the night before and the morning of the procedure (11).

Surgical Environment for Prevention of Surgical Site Infections 

There are a number of important prevention strategies related to the surgical environment, including maintaining normothermia, limiting OR traffic, and the use of supplemental oxygen. 

Normothermia 

It is highly recommended that patients undergoing surgery maintain a normal temperature during the procedure (6). Perioperative hypothermia can lead to vasoconstriction and thus reduce tissue oxygenation, which then can increase the risk for SSI (11). Ways to maintain a patient’s normal temperature include warmed blankets, warmed intravenous fluids, or forced-air warming systems (11).  

OR Traffic

It is important to limit the number of people in the OR and reduce the traffic in and out of the OR to only essential purposes. Research shows that increased traffic in the OR increases the number of airborne particles and thus microbial load in the sterile environment. This increases the risk of SSI- there is a direct relationship between traffic and SSI (2, 30, 34). 

Supplemental Oxygen 

Providing high levels of supplemental oxygen during all surgical procedures is an evolving area of research. Some studies had shown a reduction in surgical site infections when supplemental oxygen was administered to patients undergoing colorectal surgery (1). It is thought that because surgery causes a localized hypoxic state in tissues, that increasing the oxygenation to these tissues can reduce the risk of SSI. However, studies have not shown this universally. In one randomized controlled trial, patients were given 80% FiO2 via their endotracheal tube actually had higher rates of SSI than patients who had 35% FiO2 administered (28).

Conclusion 

There are many strategies to prevent surgical site infections, including from the patient side, infection prevention strategies, and the surgical environment; the most effective programs bundle all these interventions. As the number of surgical procedures is rising, it is imperative to continue to be vigilant in preventing surgical site infections.  

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate