Surgical site infections (SSIs) are a risk for the more than 10 million patients who undergo inpatient surgical procedures every year in the United States. Between 300,000 and 500,000 Americans develop SSIs annually.¹ SSIs are defined as infections related to an operative procedure that occur at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted.² Currently, SSIs occur in between 2% and 4% of all patients who undergo inpatient surgical procedures, although many of these nosocomial infections are considered preventable.¹

When not managed properly, bioburden, or the level of planktonic bacteria and concentration of biofilm colonies, can influence conditions in the wound bed and stall the healing process.³ Infections commonly progress from contamination to colonization to critical infection and are caused by the normal flora or bacteria on an individual's body.⁴ Preventing the proliferation of these microorganisms on the wound reduces the overall bioburden and can have a positive impact on the healing process. Bioburden management strategies comprise a crucial aspect of optimizing the healing environment, preventing infection, and treating an infected surgical site.

Strategies to Manage Bioburden

During the post-operative healing period, bioburden management involves several key strategies, including the following: Antimicrobial dressings: It is recommended that dressings be kept in place for at least 24 to 48 hours post-operatively; however, dressings can become a source of infection if they are not kept clean and dry. Antimicrobial dressings used can include a variety of antimicrobial agents that can work to reduce bioburden, such as silver, polyhexamethylene biguanide, medical-grade honey, povidone-iodine, and chlorhexidine gluconate.¹

Proper cleansing techniques: After the initial dressing has been removed from a surgical wound, the wound should be cleansed properly. This requires that the individual cleansing the wound cleanse their hands before touching the dressing. After donning gloves, they can then use a normal saline solution, mild soapy water, or a wound cleanser to gently dab the patient's skin and remove any dried blood, exudate, and other drainage. The wound should then be patted dry with a sterile piece of gauze, and new dressings should be reapplied as per physician's order. If the health care provider orders state that the wound be irrigated, a 19-gauge needle with a 35mL syringe should be filled with saline, soapy water, or a wound cleanser and held between one and six inches from the wound while spraying hard enough (8psi) to irrigate away drainage and discharge.⁵

Proper cleansing can prevent the formation of excessive bioburden that may escalate to an infection. Patient education: Post-operative wound care for surgical sites continues to be vital after a patient has been discharged and until wound closure. Patient education on proper wound care is essential during this time. The health care provider should furnish information on how to care for and clean the wound, how to dress the wound, and what activities should be avoided to reduce infection (such as swimming).⁶ Proper adherence to post-operative wound care guidance can prevent the introduction of contaminants that can increase the level of bioburden on the wound. Evaluation: Patients should also be educated on infection warning signs to look for that may indicate early signs of infection. Early identification and intervention, when bioburden levels are increasing, can decrease the risk that the wound will escalate into an infection.

Conclusion

Many SSIs are preventable. Managing bioburden in post-operative wounds is essential in reducing the rate of SSIs. Proper preventative strategies, such as cleansing, the use of antimicrobial dressings, and patient education on care, can reduce the risk of developing an SSI.

References

1. Mana TSC, Donskey C, Carty N, Perry L, Leaper D, Edmiston CD Jr. Preliminary analysis of the antimicrobial activity of a postoperative wound dressing containing chlorhexidine gluconate against methicillin-resistant Staphylococcus aureus in an in vivo porcine incision wound model. Am J Infect Control. 2019;47:1048-1052.

2. Agency for Healthcare Research and Quality. Surgical site infections. 2019.

3. Galloway B. Environmental factors that influence wound healing. Medline Newsroom. 2018. https://newsroom.medline.com/expert-views/environmental-factors-influen…. Accessed September 10, 2020.

4. Mouraview V, McDonald M. An implementation of next generation sequencing for prevention and diagnosis of urinary tract infection in urology. Can J Urol. 2018;25(3):9349-9356.

5. Medline Plus. Surgical wound care – open. 2020. 6. American College of Surgeons. Surgical Patient Education Program. 2018. https://www.facs.org/member-services/chapters/resources/patient-ed, Accessed September 10, 2020.