Surgical site wound infections is one of the most dreaded complications. A surgical site infection is defined as an infection that occurs at or near a surgical incision within 30 days of the procedure or within one year if an implant is left in place. The Centers for Disease Control and Prevention (CDC) estimates that approximately 500,000 surgical site infections occur annually in the United States. They are the leading cause of nosocomial infections after surgery, accounting for nearly 40 percent of nosocomial infections in surgical patients. It is associated with disability, increased mortality, increased pain and prolonged morbidity.
Postoperative infections have an enormous impact on the patient. For some their quality of life is impacted as well as a substantial increase in financial cost. These infections account for 3. 7 million excess hospital days and more than 1. 6 billion in excess costs annually. Furthermore, patients who develop surgical site infections are five times more likely to be readmitted to the hospital, 60 percent more likely to spend time in the intensive care unit and twice as likely to die compared with surgical patients without the infections (Salkind & Kavitha, 2011).
The potential consequences for patients range from increased pain and care of an open wound to sepsis and even death. Surgical site wound infections can impact anyone who goes under the knife. Although, prevention of surgical site infections is in the forefront of every physician and nurses mind we must not disregard the risk factors that some patients carry. For instance, extremes in age, poor nutritional state, obesity (>20% ideal body weight), diabetes mellitus, smoking, coexisting infections at other sites, bacterial colonization (e. g. res colonization with Aureus), immunosuppression, and prolonged postoperative stay.
Patient comorbidities is not the only statistic to take in account for surgical site infections, the operating room posing its own unique risk factors. Among these are: length of the surgical scrub, skin antisepsis, preoperative shaving, preoperative skin preparation, length of operation, antimicrobial prophylaxis, operating room ventilation, inadequate instrument sterilization, foreign material in the surgical site, surgical drains, surgical technique including hemostasis, poor closure, and tissue trauma are just a few to mention.
The US Centers for Disease Control’s (CDC) and the National Nosocomial Infection Surveillance (NNIS) risk index is the method of risk adjustment most widely used internationally. Risk adjustment is based on three major risk factors. The first one is the American Society of Anesthesiologists (ASA) score reflecting the patient’s state of health before surgery. The wound class, reflecting the state of contamination of the wound and duration of operation, reflecting technical aspects of the surgery (Sign,2014).
The ASA has five scores to rate the increase risk of surgical site infections, a score >2 is associated with the increase risk of infection. The wound class can be categorized into four classes. Classes are considered clean when no inflammation is encountered and the genitourinary tract, alimentary or respiratory tract is entered. A clean-contaminated wound is when the genitourinary tract, alimentary and respiratory tract are entered but without significant spillage. Contaminated operations where acute inflammation (without pus) is encountered, or where there is visible contamination of the wound.
And lastly, dirty is considered operations in the presence of pus, where there is previously hollow viscus, or compound/open injuries more than four hours old. Clearly, with over 500,000 surgical site infections a year some intervention and investigated research was warranted. In 2002, the Centers for Medicare and Medicaid Services (CMS), collaborating with the CDC, developed and implemented the Surgical Infection Prevention Project (SCIP). Its goal was to provide evidence-based performance measures for the appropriate selection, administration, and termination of prophylactic antibiotics for patients undergoing cleancontaminated surgeries.
Publicly reported SCIP performance measures targeted at reducing postoperative surgical site infections include the following. Prophylactic antibiotics should be initiated within one hour before surgical incision, or within two hours if the patient is receiving vancomycin or fluoroquinolones. Patients should receive prophylactic antibiotics appropriate for their specific procedure and prophylactic antibiotics should be discontinued within 24 hours of surgery completion (SCIP, 2017). According to SCIP, the goal of antibiotic prophylaxis is to ensure effective serum tissue levels of the drug for the duration of the surgery.
Analysis of data from 2,847 patients undergoing clean or clean-contaminated surgical procedure showed that those receiving antibiotic prophylaxis within two hours before incision had surgical site infection rate of 0. 6 percent. In contrast, patients receiving antibiotic more than three hours after surgical incision had a twofold increase in surgical site infection, and those receiving antibiotics more than two hours before had approximately a six fold increase in the risk (Salkind & Kavitha, 2011). Timing of the antibiotics seem to be the main factor in preventing surgical site infections.
Another study, with 2,847 patients, found the rate of infection was lowest for patients who received an antibiotic from 0 to 2 hours before the incision. Specifically, of the 1,708 patients who received prophylactic antibiotics during this time frame, only 10 (0. 6%) subsequently developed a surgical site infection compared to 14 (3. 8%) of 369 patients who received antibiotics 2-24 hours preoperatively, and 4 (1. 4%) of 282 patients who received antibiotics 3-24 hours following the incision (Dhammi et al. , 2015).
Another important component in the reduction of surgical site infections is the choice of antimicrobial agents used before surgery. According to Belden, Silver bovsky, & Vogt (2013), the drug chosen should be active against the pathogens most commonly associated with wound infections following the specific procedure and against the pathogens endogenous to the region of the body being operated. Selection of an appropriate agent for specific patients should take into account not only comparative efficacy but also adverse effect profiles and patient drug allergies.
For most procedures, cefazolin 1 gram or cefoxitin 2 gram should be the agent of choice because of their relatively long duration action, their effectiveness against the organisms most commonly encountered in surgery, and their relatively low cost. Clindamycin or vancomycin should be used in penicillin-allergic patients. Unfortunately, despite the demonstrated reductions in the incidence of surgical site infections following the implementation of these measures a recent study according Dr. Alan Salkind and Kavitha Rao of Kanas City School of Medicine found that U. S. hospitals are not routinely following the guidelines.
Only 55. 7 percent of surgical patients received prophylactic antibiotics within one hour of incision, and the antibiotic was discontinued within 24 hours after surgery in only 40. 7 percent of patients. As stated before, timing is everything when reducing surgical site infections. The problem lies in operations being delayed or the healthcare perfessional simply forgetting to administer the antibiotic in a timely manner. Additonally research has been done on the use of antibiotic prophylaxis admistered intraincisionally, intranasally, or through silver or honey-impregnated dressing.
In an evidence based review article written by Rosengren H Dixon states, “The use of intraincisional antibacterial prophylaxis for the prevention of surgical site infections has provided some encouraging results. In delayed closure procedures, intraincisional clindamycin administered with local anaesthetic resulted in lower infection rates (0. 7% vs 2. 4%) compared to anaesthetic alone. ” Futhermore, using inteaincisional, and intranasal prophaylatic antibiotics instead of intravenous antibiotics, will remove the timeing aspect from the equation but would also reduce antimicrobial resistance.
Another advantage is that it would lessen adverse side effects, although contact dermatitis could be a potential problem. A significant risk factor for developing infection after surgery is a patient that has a nasal carriage of S. aureus. Being a carrier of S. aureus increases the likeliness of surgical site infection 2-9 times. Dixion states in a report ” That eradication of S. aureus nasal carriage by administration of intranasal mupirocin led to statistically fewer S. aureus infections than placebo or no treatment. “
