Surgical site infections (SSIs) account for 20% of total documented infections each year and cost approximately $34,000 per episode. SSIs are responsible for increased readmission rates, length of stay, reoperation, morbidity, and mortality, as well as increased overall health care costs.^1,2 A 2008 estimate from the Centers for Disease Control and Prevention (CDC) suggests that diagnosis of SSI is associated with increases in hospital length of stay of up to one to two weeks and a risk of death nearing 10-fold that of patients without SSI.³ Although the sequelae and associated financial impact of SSI are dependent on multiple factors—including patients’ status before surgery, type of surgical procedure, and treatment of identified pathogen—annualized estimates have reached $10 billion.²

Factors contributing to SSI can be patient-specific and may be either modifiable or non-modifiable. Other aspects of care influencing SSI development include those related to the health care setting, specifically steps that occur in the pre-, intra-, and post-operative phases. To best prevent the occurrence of SSI, multiple factors must be addressed.

Risk Factors Related to SSI

Patient-specific risk factors are potentially the most difficult to mitigate. Clinicians must deploy evidence-based strategies to combat non-modifiable factors, including advanced patient age, past medical history including radiation and compromised blood flow from vascular harvest procedures, personal history of delayed healing or complex infections, long-term corticosteroid use, mobility limitations, and history of complications with anesthesia, to name a few.

We are able to affect some modifiable patient-specific risk factors to a greater degree than others. Some of the most prevalent modifiable risk factors or disease states include obesity, overall functional status, malnutrition, diabetes, smoking status, alcohol or substances abuse, coagulopathy, issues affecting perfusion (hypertension, coronary artery disease, peripheral arterial disease, respiratory conditions), and other metabolic states that affect the quality of the host defenses.⁴ If the surgical procedure is an emergency operation, pre-operative risk management is impossible; this creates a need for proficient mitigation of such factors in the perioperative period.

Perioperative Guidelines for Prevention of SSI

Many organizations have published documents that identify measures to prevent or decrease the incidence of SSI, including the American College of Surgeons (ACS),⁵ the American Society of Colon and Rectal Surgeons (ASCRS),⁶ the Association of periOperative Registered Nurses (AORN),⁷ the CDC,¹ The Joint Commission (TJC)⁸—formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)—and the World Health Organization (WHO).⁹

All offer a set of recommendations or guidelines regarding SSI prevention and include similar points aimed at patient-specific risk factors and interventions throughout the phases of care (pre-hospital, hospital, and post-discharge). The variances noted among the documents are related to differing interpretations of available literature evidence and data, intended audience, and health care organization priorities. The potential for international consensus is low overall because of the unique nature of many patient populations and geographic locations, including available resources. For succinctness and ease of understanding, we will limit this discussion to the CDC strategies for SSI prevention, as outlined here.

• Shower or bathe patients before surgery with soap (antimicrobial, non-antimicrobial, or antiseptic agent) at least the night before surgery.
• Administer antimicrobial prophylaxis only when indicated based on published clinical practice guidelines and timed such that the agent’s bactericidal concentration is established in the serum and tissues on incision.
• Antimicrobial prophylaxis should be administered before skin incision in cesarean section procedures.
• Operating room skin preparation should be performed using an alcohol-based agent unless contraindicated.
• For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain.
• Topical antimicrobial agents should not be applied to the surgical incision.
• Glycemic control should be implemented using blood glucose target levels less than 200mg/dL during surgical procedures.
• Maintain normothermia in all patients undergoing surgical procedure.
• Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate post-operative period for patients with normal pulmonary function who are undergoing general anesthesia with endotracheal intubation.
• Blood transfusion products should not be withheld from surgical patients as a means of preventing SSIs.

Topical Management

There is some advocacy for the use of closed incisional negative pressure therapy (ciNPT) for specific procedures and patient populations for SSI prevention, although ciNPT is not recommended for ubiquitous use. There is evidence to support ciNPT use in groin incisions in vascular procedures, open abdominal incisions in colorectal procedures, and select high-risk patients.^1,5

Current guidelines do not completely agree on the use of antimicrobial agents over closed surgical incisions for prevention of SSI; some studies show topical mupirocin can decrease SSI risk compared with standard gauze dressing,⁵ whereas the CDC does not recommend topical antibiotic use for this purpose. The ACS does suggest the use of topical antibiotics can reduce SSI in spine surgery, total joint arthroplasty, and cataract surgery but does not advocate for routine use.⁵

Implications for Practice

The viability of health care systems is dependent on appropriate utilization of resources. Understanding the incidence, economic, clinical, social, and psychological impact of SSI is crucial for health care facilities; understanding the sequelae will assist with a proactive versus reactive approach regarding SSI. SSIs are considered a “never” event by the Centers for Medicare & Medicaid Services, and reimbursement for services provided by a given facility is negatively affected by SSI rate.¹⁰

Surveillance of SSI rates is proven to contain costs, but few health care facilities have invested in programs for such purposes. This makes the burden of SSIs even more difficult to quantify and may negatively skew the data that contribute to developing effective prevention measures.¹¹

References

1. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection. JAMA. 2017;152(8):784–91.

2. How-to Guide: Prevent Surgical Site Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. (Available at www.ihi.org).

3. Centers for Disease Control and Prevention (CDC). Surgical site infection (SSI). 2016. ww.cdc.gov/HAI/ssi/faq_ssi.html . Accessed September 12, 2018.

4. Harris CL, Kuhnke J, Haley J, et al. Best practice recommendations for the prevention and management of surgical wound complications. Wounds Canada. https://www.woundscanada.ca/docman/public/health-care-professional/bpr-…. Accessed September 18, 2018.

5. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg. 2016;224:59–74.

6. American Society of Colon and Rectal Surgeons

7. Association of periOperative Registered Nurses

8. The Joint Commission

9. World Health Organization

10. Centers for Medicare & Medicaid. Hospital-acquired condition (HAC) reduction program. 2018. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Ins…. Accessed September 18, 2018.

11. Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(6):605–27.

Resource

American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/resources/clinical-information/asa-physical-statu…. 2014. Accessed September 18, 2018.