Prevention and Treatment of Surgical Site Infection Essay Paper

Prevention and Treatment of Surgical Site Infection Essay Paper

Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). A prevalence survey undertaken in 2006 suggested that approximately 8% of patients in hospital in the UK have an HCAI. SSIs accounted for 14% of these infections and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, prevalence studies tend to underestimate SSI because many of these infections occur after the patient has been discharged from hospital. SSIs are associated with considerable morbidity and it has been reported that over one-third of postoperative deaths are related, at least in part, to SSI. However, it is important to recognise that SSIs can range from a relatively trivial wound discharge with no other complications to a life-threatening condition. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic or keloid, persistent pain and itching, restriction of movement, particularly when over joints, and a significant impact on emotional wellbeing. SSI can double the length of time a patient stays in hospital and thereby increase the costs of health care. Additional costs attributable to SSI of between £814 and £6626 have been reported depending on the type of surgery and the severity of the infection. The main additional costs are related to re-operation, extra nursing care and interventions, and drug treatment costs. The indirect costs, due to loss of productivity, patient dissatisfaction and litigation, and reduced quality of life, have been studied less extensively.Prevention and Treatment of Surgical Site Infection Essay Paper

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Surgical site infection (SSI) are the third most frequently reported nosocomial infection, and the most common on surgical wards [1]. The Centers for Disease and Prevention (CDC) estimates that 22% of all the health-care-associated infections are SSI, with an increasing percentage over the last decennium [1, 2]. SSI increase morbidity as well as mortality, double the length of hospital stay [3–6] and increase the cost of surgery two-fivefold [7]. Kirkland et al. showed that 60% of the patients who develop an SSI are more likely to be admitted to an intensive care unit (ICU), or to be hospitalized for another 5 days and more than five times more likely to be re-admitted. Therefore, SSI rates are increasingly seen as a performance indicator for the quality of health care [8]. In 2009, the World Health Organization issued guidelines on how to prevent SSI in developed as well as in developing countries [9].

Postoperative wound infections, also known as surgical site infections (SSIs), complicate the recovery course of many patients. As defined by the Centers for Disease Control and Prevention (CDC), these infections typically occur within 30 days of an operation at the site or part of the body where the surgery took place, or within a year if an implant is left in place and the infection is thought to be secondary to surgery.1–3 Bacterial colonization on the patient’s skin and alimentary and genital tract are the principal contributing sources that lead to SSIs.4 The organism most often isolated is Staphylococcus aureus.5 Exogenous sources, such as breaches in sterile technique and operating room equipment may contribute, albeit much less frequently than endogenous flora.6 Bacteria within the tissue or organ space hinder the postoperative healing processes, and can lead to anastomotic leaks, wound dehiscence, and superficial incisional infections.Prevention and Treatment of Surgical Site Infection Essay Paper

SSIs may be classified as superficial/incisional if limited to the skin and subcutaneous tissue, deep incisional when involving the fascia and muscle, or organ space when involving a body cavity (eg, abdominal cavity following gastrointestinal surgery).2,3 Deep tissue and organ space SSIs are less frequently encountered than superficial SSIs, but are associated with greater morbidity/mortality, readmission rates, longer hospital stay, and increased overall hospital-associated costs when compared with superficial SSIs.7–9 Although the majority of SSIs are uncomplicated, others may be severe and more challenging to manage, such as necrotizing deep soft tissue infections.2,8 The latter often require extensive surgical debridement, multiple reoperations, and may even be life-threatening.10,11 The location and extent of the infection, as well as the patient’s clinical condition, guide the management approach.2,10 For instance, in the setting of an implant, as in the case for a synthetic mesh in an infected wound, oftentimes explantation of the implant is required, which may add to the postoperative morbidity. Furthermore, appropriate antibiotic therapy is often necessary to achieve source control in such patients.

With the rising incidence and associated morbidity of SSIs, various studies have looked at ways to better optimize patients prior to surgery or improve surgical technique and management of patients during the recovery period in order to prevent SSIs.12,13 Data regarding a hospital’s rate of SSIs are becoming increasingly used as outcome measures for assessing the quality of their surgical services.14,15 Employing methods that could reduce the incidence of SSI would significantly reduce patient morbidity and mortality while lessening the associated economic burden; this has become central to quality improvement initiatives.16 Herein, the authors provide an update on the epidemiology, risk factors, identification, and management of wound infections following abdominal surgery.Prevention and Treatment of Surgical Site Infection Essay Paper

Epidemiology and impact

Incidence and trends

Overall, it is estimated that SSIs occur following 1%–3.1% of all surgical procedures and account for approximately 2.0% of deaths due to health care-associated infections (HAIs).2,7,17–20 With regard to abdominal surgery, the rate of wound infection may be much higher, with several prospective studies reporting an incidence of 15%–25% depending on the level of contamination.21–24 A recent study reviewing the reasons for hospital admissions after surgery in the USA demonstrated that SSI was the most common reason for unplanned readmission (19.5% overall, 25.8% following colectomy/proctectomy) followed by obstruction/ileus (10.3% overall).25 When considering HAIs, survey data gathered by 183 acute-care hospitals in 2011 estimated that 157,500 of 721,800 (21.8%) cases were SSIs.26 Compared to other common nosocomial infections, SSIs (21.8%) and pneumonia (21.8%) were the most commonly reported, followed by gastrointestinal (17.1%), urinary tract (12.9%), and bloodstream infections (10.0%).26 The number of SSIs reported is likely an underestimate of the true incidence, as many are diagnosed in an outpatient setting or after discharge.2

In general, the rate of SSI for men appears to be higher than that of women across several studies.8,27–29 Also, the topic of SSI rate in the elderly is becoming an increasingly important area for research. As patients are living longer, the number of elderly patients undergoing general surgical procedures will certainly increase, and complications such as SSIs in patients aged ≥65 years will become a more apparent issue for general surgeons.28,30 Although the relationship between increasing age and risk of SSI is complex, it is well known that related mortality rate, hospital stay, and health care-related costs for older patients with SSIs are greater than that for younger patients.28 The impact of age and sex on SSI risk will be discussed later in the text.Prevention and Treatment of Surgical Site Infection Essay Paper

Economic impact

Health care costs associated with treating SSIs are exceedingly high.30–33 A study performed in Veterans Affairs Hospitals demonstrated a 1.43-fold relatively higher hospital cost for patients with an SSI ($11,876 difference) than for patients without an SSI.32 Similar total excess costs ($10,497) have been reported for patients with SSIs from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) when compared to those without SSIs.29 Even more striking, data from the 2005 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS) highlighted that SSI extended hospital length of stay by nearly 10 days, and hospital-associated costs increased by approximately $20,842.18 Nationally, 91,613 readmissions due to SSIs were reported in 2005, and overall associated hospital costs exceeded $900 million.18 Furthermore, from 1993 to 2005, the number of emergency department visits in the USA for skin and soft tissue infections (SSTIs) increased from 1.2 million to 3.4 million. Of all emergency department visits, SSTIs constituted 1.35% in 1993, increasing to 2.98% in 2005.34 A separate study demonstrated that between 2000 and 2004, total hospital admissions increased by 29% for SSTIs.35 Similar trends are highlighted at the state level. In North Carolina, the most common HAIs are SSIs (73%), and related costs approximated 87%–91% of the total HAI-related expenditure.36 These excess costs are largely related to antimicrobial/drug treatment, interventions, and additional nursing care

Surgery that involves a cut (incision) in the skin can lead to a wound infection after surgery. Most surgical wound infections show up within the first 30 days after surgery.Prevention and Treatment of Surgical Site Infection Essay Paper

Surgical wound infections may have pus draining from them and can be red, painful or hot to touch. You might have a fever and feel sick.

Causes
Surgical wounds can become infected by:

Germs that are already on your skin that spread to the surgical wound
Germs that are inside your body or from the organ on which the surgery was performed
Germs that are in the environment around you such as infected surgical instruments or on the hands of the health care provider.
You are more at risk for a surgical wound infection if you:

Have poorly controlled diabetes
Have problems with your immune system
Are overweight or obese
Are a smoker
Take corticosteroids (for example, prednisone)
Have surgery that lasts longer than 2 hours
There are different levels of wound infections:

Superficial — the infection is in the skin area only
Deep — the infection goes deeper than the skin into the muscle and tissue
Organ/space — the infection is deep and involves the organ and space where you had surger

 

Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) is a worldwide pandemic. In recent years, the number of HIV-infected patients is progressively increasing. The introduction of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients infected with HIV and those diagnosed with AIDS [10–15]. The demand for surgical treatment in HIV-infected patients combined with surgical disease is on the rise [16, 17]. The progressive failure of the immune system in patients caused by HIV can increase the possibility of developing surgical site infections after surgery. The aim of this study was to determine the incidence and the associated risk factors for SSI in HIV-infected patients. And we also explored the preventive measures.Prevention and Treatment of Surgical Site Infection Essay Paper

Approximately 27 million surgical procedures are performed in the United States each year, with up to 5% resulting in surgical site infections (SSI). Trends in the incidence of SSI are monitored by the National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC). According to NNIS data, SSIs are the third most frequently reported nosocomial infection and are associated with substantial morbidity that can endanger a patient’s life, increase the number of days in the hospital, and increase healthcare costs. This chapter describes the types of SSI, lists risk factors, and explains prevention strategies.

What are surgical site infections?
Surgical site infections are defined as infections that occur 30 days after surgery with no implant, or within 1 year if an implant is placed and infection appears to be related to surgery. Infections are classified as either incisional or organ/space infections to differentiate those that occur at the incision site from those related to the organ or space manipulated during surgery. Incisional infections are further classified as superficial or deep.

Characteristics of SSIs are summarized in Table I.

What is the incidence of surgical site infections?
In the United States, the incidence of SSI is tracked by the National Nosocomial Infections Surveillance (NNIS) system and the National Hospital Discharge Survey, both sponsored by the CDC. The American Hospital Association also compiles statistics through an annual survey. A study by Klevens RM et al using all of these data sources determined that 244,385 SSIs were reported in U.S. hospitals in 2002, accounting for 20% of all healthcare-associated infections and nearly 2% of all monitored surgical procedures.Prevention and Treatment of Surgical Site Infection Essay Paper

What are the consequences of surgical site infections?
Surgical site infections are associated with substantial morbidity and mortality. Patients with SSI are twice as likely to die, 60% more likely to be admitted to the intensive care unit, and more than five times more likely to be readmitted to the hospital after discharge. In 2002, SSIs contributed to 8205 deaths. Occurrence of SSI is estimated to increase hospital stay by 7 to 10 days and add over $3,000 in costs of care. In a comparison study (Kirkland KB, 1999) of surgical patients with vs. without infection, the median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. Patients who were readmitted after discharge incurred higher costs of over $5,000.

Higher costs of care were reported in a 2009 study by a CDC economist (Scott RD), who estimated the cost of treating SSI at $10,443 to $25,546. At a rate of 5 SSIs per 100 surgical procedures, the total annual cost of treating SSIs was projected at $3.2 to $10 billion. These wide variations in cost of care reflect the complex nature of SSIs, which may substantially differ in severity depending on the causative pathogen, type of surgical procedure performed, patient’s underlying health condition, and other factors.

What is the microbiology of surgical site infections?
Surgical site infections may be caused by endogenous or exogenous microorganisms. Most SSIs are caused by endogenous microorganisms present on the patient’s skin when the surgical incision is made. Gram-positive bacteria such as Staphylococcus aureus are the most common causative skin-dwelling microorganisms. Surgical site infections may also be caused by organisms within the patient’s body that are exposed during surgery. Causative pathogens depend on surgical site; for example, the risk of developing SSI from enteric gram-negative microorganisms increases with surgery on the gastrointestinal tract. Exogenous sources of microorganisms include surgical instruments, operating room surfaces, the air, and personnel.Prevention and Treatment of Surgical Site Infection Essay Paper

The most common pathogens responsible for SSI are presented in Table II.

How important is the issue of antibiotic resistance in the context of surgical site infections?
The risk of SSI caused by resistant bacteria has become a major concern for hospitals and healthcare professionals. “Resistance” is the term used to describe the ability of a microorganism to withstand the effects of an antimicrobial agent. Microorganisms acquire resistance through evolution and adaptation. In particular, there is concern about the rise in SSIs due to vancomycin-resistant enterococci (VRE), Methicillin-resistant Staphylococcus aureus (MRSA), third generation cephalosporin-resistant Escherichia coli, and imipenem- and quinolone-resistant Pseudomonas aeruginosa.

What are the consequences of antibiotic resistance on surgical site infections?
The development of resistant microorganisms can result in increased morbidity, mortality, and costs of care. For example, in one study the presence of MRSA in a surgical incision was associated with a 12-fold increase in 90-day postoperative mortality, compared with uninfected patients. Hospitalization stays for these patients increased a median of 5 days, and median costs of care were nearly $40,000 higher for MRSA-infected patients compared with uninfected patients. Hospitalized patients with VRE had a 6% increased risk of mortality, 6.2 days of excess hospitalization, and $12,766 in additional hospital costs, compared with uninfected patients. Hospital costs attributable to nosocomial infections caused by resistant bacteria have been conservatively estimated at $1.6billion per year in the United States.

Which factors predispose an individual to surgical site infections?
Risk factors for developing SSI can be broadly grouped by patient, wound, and procedural variables. Patient variables that increase risks for SSI include the following:Prevention and Treatment of Surgical Site Infection Essay Paper

Very young or very old age

Diabetes (especially increased HgA1c and glucose ³200 mg/dL within 48 hours after surgery)

Tobacco use

Steroid use

Compromised immune system

Infection or colonization at a remote body site

Obesity

Poor nutritional status

Length of preoperative stay (increases exposure to pathogens)

Wound contamination

What is the relationship between wound contamination and surgical site infections?
Wound contamination is a significant risk factor for developing SSI. In 1964 a classification system was developed to categorize wounds based on the degree of microbial contamination present. The wound is classified by a member of the surgical team and used as one variable to assess the risk of SSI.

This classification system is presented in Table III.

Which procedural variables affect surgical site infections?
Procedural variables include factors related to preoperative skin preparation, sterilization protocols, and the surgery itself. Procedural variables that can affect the risk for SSI include the following:

Antimicrobial prophylaxis

Duration of surgical scrub

Preoperative hair removal

Skin antisepsis protocol

Choice of preoperative skin preparation

Operating room ventilation

Wound class

Sterilization of instruments and environment

Foreign matter in the surgical site

Surgical techniques

Duration of surgery

How is the risk of surgical site infections stratified?
Two SSI risk stratification systems have been developed. The Study on the Efficacy of Nosocomial Infection Control (SENIC) project determined that the risk for an SSI increases for patients with the following criteria:Prevention and Treatment of Surgical Site Infection Essay Paper

Abdominal surgery

Operation lasting >2 hours

Class III or Class IV wound classification (contaminated or dirty-infected)

Surgery performed on a patient with 3 or more discharge diagnoses

The National Nosocomial Infections Surveillance System (NNIS) index assesses higher SSI risk when the following variables are present:

Class III or Class IV wound classification (contaminated or dirty-infected)

Length of operation > T hours, where T is the 75th percentile of the duration of the specific operation being performed

American Society of Anesthesiology (ASA) Physical Status Classification of >2, as follows:

P1 A normal healthy patient

P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A declared brain-dead patient whose organs are being removed for donor purposes

How can surgical site infections be prevented?
SSI Prevention Strategies

The most effective SSI prevention strategies involve a multi-faceted approach including protocols exercised before, during, and after surgery to reduce exposure and susceptibility to pathogens. Several infection control guidelines and initiatives are available to serve as a foundation for hospital programs to reduce the incidence of SSI. Guidelines are summarized in the section titled, Initiatives to Reduce SSIs.Prevention and Treatment of Surgical Site Infection Essay Paper

Prevention strategies can be categorized as follows:

Preoperative patient preparation

Tobacco cessation

Antimicrobial prophylaxis

Preoperative showering

Hair removal

Preoperative skin antisepsis

Preoperative scrubbing

Perioperative techniques

Prevention of intraoperative hypothermia

Glucose monitoring

Perioperative hyperoxia

Incision care

What is the role of tobacco cessation in surgical site infections?
Use of tobacco products has been associated with higher rates of SSI. Nicotine use delays wound healing, and cigarette smoking is an independent risk factor for the development of SSI. For elective procedures, patients should be encouraged to stop using all tobacco products at least 30 days prior to surgery.

How can antimicrobial prophylaxis be optimized?

Antimicrobial Prophylaxis (AMP)

Antimicrobial prophylaxis (AMP) refers to a short course of antimicrobial therapy administered prior to surgery to reduce microbial counts to a level that will not overwhelm host immune response. Antimicrobial prophylaxis should be administered only for Class I and II wounds. Patients with Class III or IV wounds are presumed to be taking antimicrobial therapy already. Optimal AMP therapy requires:

Use of the correct agent for the type of operation, based on clinical evidence

Cephalosporin for coverage of most clean procedures due to its safety, broad-spectrum efficacy and low cost

Appropriate timing of administration:

30 to 60 minutes prior to incision (i.e., enough time to reach bactericidal serum and tissue concentrations); 1-2 hours for antibiotics with longer periods of infusion, such as vancomycin

Re-administration if surgery is delayed beyond 1 hour after the first AMP dose

Maintained at therapeutic levels in both serum and tissues throughout surgery  Prevention and Treatment of Surgical Site Infection Essay Paper

Lasting no longer than 24 hours after the end of surgery to reduce risk of developing resistance

Is preoperative showering effective for infection control?
The CDC recommends that patients shower preoperatively using an antiseptic to reduce microbial counts on the skin prior to surgical incision. Using chlorhexidine gluconate is associated with a 9-fold reduction in microbial counts on skin. In one study, the SSI rate was lower among patients who showered with chlorhexidine (9%) compared to those who showered with bar soap (12.8%) or placebo (11.7%). The Association of Operating Room Nurses (AORN) recommends that patients undergoing Class I (clean) procedures take two showers with chlorhexidine gluconate 4% solution the night before surgery. For surgeries involving the head, two preoperative shampoos with chlorhexidine gluconate 4% solution are recommended.

Is hair removal an effective method of infection control?
Hair removal was once theorized to reduce the risk of post-operative infection and, accordingly, became routine practice in many operating rooms. In fact, shaving creates small cuts and microabrasions in the skin in which bacteria can collect and multiply and is associated with increased incidence of SSI. Shaving longer than 24 hours prior to surgery is associated with a higher SSI risk than shaving immediately prior to incision. Hair removal using a depilatory is not associated with increased SSI risk but can produce skin irritation. If hair removal is necessary, clipping, rather than shaving, is recommended and should be done immediately prior to surgery.

What constitutes optimal skin antisepsis?
Given the strong correlation between the presence of skin-dwelling microorganisms and infection, it is critical to adequately disinfect the surgical site prior to incision to decrease the risk of SSI. U.S. Food and Drug Administration (FDA) criteria for a recommended antiseptic agent include the following characteristics:

significantly reduces microorganisms on the skin

contains an antimicrobial agent

provides broad-spectrum coverage

is fast-acting

has a sustained effect

Other considerations in choosing an antiseptic agent include patient allergy or sensitivity to ingredients, surgeon preference, and location of incision. Product label recommendations and warnings should be closely followed. Commonly used skin antiseptics include alcohol, chlorhexidine gluconate, and iodine/iodophors.Prevention and Treatment of Surgical Site Infection Essay Paper

Table IV lists characteristics of commonly used agents for surgical antisepsis.

A recent landmark study evaluated the rate of SSI in patients prepped preoperatively either with chlorhexidine gluconate plus alcohol solution or with povidone-iodine. In this randomized, controlled, multicenter trial, 897 patients undergoing clean-contaminated surgery were randomized to have their skin disinfected preoperatively with either 2% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) or 10% povidone-iodine. The primary endpoint was the occurrence of any SSI within 30 days after surgery. The occurrence of individual types of SSI was a secondary endpoint. Surgeons were unblinded, whereas patients and investigators who diagnosed SSI were blinded to the antiseptic product used.

Patients were contacted weekly following discharge, up to 30 days post-procedure. If SSI was diagnosed or suspected, cultures were taken to confirm the presence of microorganisms. The overall rate of infection was significantly lower in patients prepped with CHG/IPA (9.5%) compared to those prepped with povidone-iodine (16.1%, P=0.004). The risk of SSI was reduced 41% for patients prepped with CHG/IPA compared to those whose skin was disinfected with povidone-iodine. There were also significantly fewer superficial incisional and deep incisional infections in the CHG/IPA arm.

What is the impact of preoperative scrubbing on infection control?
In addition to reducing microorganisms on patient skin, all healthcare professionals who have direct contact with patients during surgery should reduce microbial counts on their own skin. Staff who prepare patients for surgery must thoroughly disinfect their hands prior to touching the patient. Similarly, surgical team members must undergo preoperative scrubbing of hands and forearms. Arms and hands should be scrubbed for at least 5 minutes before the first surgery each day, and between 2 to 5 minutes before each subsequent procedure. The antiseptic used as a scrub agent should contain broad-spectrum antimicrobial properties. Scrubs containing chlorhexidine gluconate produce a greater antimicrobial effect than other antiseptics. The addition of alcohol to chlorhexidine gluconate provides more persistent effects than povidone-iodine alone. A study demonstrated that the rubbing with chlorhexidine gluconate and alcohol produced a >50-fold reduction in bacterial counts on the hands, while the use of the comparator, povidone-iodine scrub, resulted in only a 3-fold reduction.Prevention and Treatment of Surgical Site Infection Essay Paper

What is the relationship between intraoperative hypothermia and surgical site infections?
Intraoperative hypothermia can contribute to SSI by producing vasoconstriction that reduces blood flow to the incision site and limits delivery of oxygen to the tissue surrounding the wound. In a study that evaluated the effects of hypothermia on SSI rates, 200 patients undergoing colorectal surgery were randomly assigned to routine intraoperative thermal care (the hypothermia group) or additional warming (the normothermia group). Patients in the hypothermia group developed significantly more SSIs post procedure than the normothermia group (19% vs. 6%, respectively). Additionally, the average number of days in the hospital was higher for the hypothermia group compared to the normothermia group. To avoid hypothermia, staff could use blankets, warmed intravenous fluids, or forced air warming to maintain the patient’s core temperature throughout surgery, where feasible.

Are there controversies associated with forced air warming?
A number of devices have been introduced to provide forced air warming to prevent hypothermia. A commonly used system includes a “blanket” attached to a forced air unit. The blanket is designed to distribute warmed air evenly over the portion of the patient’s body. These devices have demonstrated efficacy in preventing hypothermia, which is also associated with improved tissue viability and reduced incidence of bed sores. However, recent reports in the literature question whether inadequately filtered air from the blowers may be contaminated with pathogens, exposing patients to increased risks of infection. Another theory is that forced air may mobilize microorganisms on the patient’s skin. Analysis of bacterial contamination in operating room air and around and on patients’ bodies has not demonstrated increased risks of infection when forced air units are used.

How can surgical site infections be reduced by improving glucose control?
High blood glucose levels are associated with increased risk of SSI, regardless of the presence of diabetes . A study of 647 patients undergoing major non-cardiac surgery showed that post-surgery infections were related to hemoglobin A1c (HbA1c) levels. Specifically, HbA1c levels below 7% were associated with significantly fewer infections following surgery. Among patients with diabetes, several studies suggest that failure to control blood glucose before and after surgery correlates with the development of SSIs. Blood glucose levels should be controlled in patients with diabetes both before and after surgery to reduce SSI risk.Prevention and Treatment of Surgical Site Infection Essay Paper

Is hyperoxia a controversial means of infection control?
Surgery disrupts the vascular delivery of oxygen to the wound site, leading to a hypoxic state in wound tissue. Supplemental oxygen has been suggested as a means of improving oxygenation and possibly decreasing the risk for SSI. Studies of supplemental oxygenation have produced contradictory results, however. In a randomized controlled study (Pryor KO et al, 2004) of patients undergoing abdominal surgery, the incidence of infection was significantly higher in the group receiving 80% oxygen than in the group receiving 35% oxygen (25% vs. 11.3%, respectively; P=0.02).

In contrast, a meta-analysis (Al-Niaimi A et al, 2009) of randomized, controlled trials evaluating the efficacy of supplemental perioperative oxygenation vs. standard care for prevention of SSI in patients undergoing colorectal surgery found a reduced incidence of SSI (R 0.70 [95% CI 0.52-0.94]; P=0.01). The authors stated that their analysis demonstrated that supplemental perioperative oxygenation is beneficial in preventing SSI in patients undergoing colorectal surgery and recommended further study of results from other types of surgery. Although supplemental oxygen appears to offer benefits, it is not a standard recommendation.

What is the effect of incision care on surgical site infections?
Patients tend to prefer wound closures that will minimize scarring, but not all surgical wounds should be closed. A prospective study revealed higher wound infection rates when contaminated abdominal incisions were closed after surgery compared to packing for 3 days and evaluating for signs of infection prior to closure (Cohn SM et al, 2001). With respect to drains, the data are unclear as to their effectiveness in preventing SSI. Some studies showed that drains in clean or clean-contaminated wounds do no affect on the development of SSI, while others show an increase in infection.

Which initiatives have been promoted as a means of reducing surgical site infections?
Initiatives to reduce SSI focus on aspects of risk ranging from improving control of the physical care of the patient to information-gathering efforts such as broader reporting of infection rates. Major initiatives are described in this section.Prevention and Treatment of Surgical Site Infection Essay Paper

Guideline for Prevention of Surgical Site Infection, 1999: The Centers for Disease Control and Prevention (CDC) published one of the most comprehensive and widely-used SSI guidelines in the United States. The CDC guidelines provide specific details about risk and prevention of SSI. Information includes patient characteristics that contribute to increased SSI risk, such as diabetes, smoking, or prolonged hospital stay. Evidence-based information is provided about preoperative, operative, and postoperative procedures that have been clinically demonstrated to reduce infection risk. Surveillance methods with appropriate feedback to surgeons and infection control professionals are described to assist institutions in monitoring the incidence of SSI. Each recommendation in the CDC guideline is ranked by the level of scientific information available to support it. An updated guideline is currently being formulated by the CDC.

National Healthcare Safety Network (NHSN): The National Healthcare Safety Network (NHSN) is a voluntary, Internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at the CDC. Data are collected from participating healthcare facilities to estimate adherence to practices known to be associated with prevention of healthcare-associated infections (HAIs). The NHSN conducts research with member facilities to gather data about the epidemiology of emerging HAIs and pathogens, assess risk factors, determine mechanisms of resistance, and evaluate prevention strategies.Prevention and Treatment of Surgical Site Infection Essay Paper

Guidance on Public Reporting of Healthcare-Associated Infections: The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) has established a guidance document for reporting healthcare-associated infections. This document is designed to assist policymakers who create mandatory public reporting systems to track health-associated infections. The HICPAC recommendations suggest using outcome measures including surgical antimicrobial prophylaxis and SSIs following selected procedures.

AORN Perioperative Standards and Recommended Practices:The Association of Operating Room Nurses (AORN) publishes annual guidelines that include recommended skin preparation procedures designed to reduce damage to skin tissue and decrease the risk of infection. Specific guidelines include:

Assessing and documenting the condition of the surgical site before skin preparation

Leaving hair intact at the surgical site whenever possible to avoid skin damage during removal

Thoroughly cleaning the surgical site

Applying an antiseptic agent to the surgical site and surrounding areas

Preparing the skin in a manner that preserves skin integrity and prevents injury

Institute for Healthcare Improvement 5 Million Lives Campaign: The Institute for Healthcare Improvement (IHI) launched the 5 Million Lives Campaign to improve the quality of American healthcare by protecting patients from 5 million incidents of medical harm between December 2006 and December 2008. As part of the ongoing campaign, the IHI developed a guideline publication designed to share best practice knowledge for the prevention of SSI. These practices include 4 components of care:Prevention and Treatment of Surgical Site Infection Essay Paper

1. Appropriate use of prophylactic antibiotics

2. Appropriate hair removal

3. Controlled 6 a.m. postoperative serum glucose in cardiac surgery patients

4. Immediate postoperative normothermia for colorectal surgery patients

Surgical Care Improvement Project (SCIP):SCIP is a national quality partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications. The goal of the partnership is to save lives by reducing the incidence of surgical complications by 25% by the year 2010. Infection prevention processes and outcome measures include:

Prophylactic antibiotic received within 1 hour prior to surgical incision

Prophylactic antibiotic selection for surgical patients

Prophylactic antibiotics discontinued within 24 hours after surgery end

Cardiac surgery patients with controlled 6 a.m. postoperative blood glucose

Surgery patients with appropriate hair removal

Colorectal surgery patients with immediate postoperative normothermia

Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period

What is the interplay between surgical site infections and transplantation?
Healthcare-associated infections associated with solid organ transplantation (SOT) are problematic due to the invasiveness of the surgical procedures used, underlying disease, and immunosuppressive treatments. In one retrospective cohort study that assessed infection rates in 81 patients undergoing SOT over 14 months, the overall healthcare-associated infection rate was 42%, with 15% attributed to SSI. This study found that the length of surgery also contributed to high SSI rates. The authors concluded that stricter controls in controllable factors in this patient population, such as length of surgery, are necessary to reduce the substantially higher SSI rate associated with SOT.Prevention and Treatment of Surgical Site Infection Essay Paper

What is the impact of xenotransplantation on surgical site infections?
Xenotransplantation is the transfer of viable cells, tissues, or organs from nonhuman animal species for therapeutic use in humans. Xenotransplantation is thought to be a potential solution to the shortage of human organs and other tissues for transplantation, but the introduction of non-human living cells into a human immunological system poses risks for development of xenogeneic infections. Specifically, human recipients of xenografts may be exposed to endogenous retroviruses present in the genomes of other species.

While infections are always a risk in transplant (allograft) patients, xenograft recipients may be at increased risk due to the greater levels of immunosuppression needed and the novel mechanisms of pathogens found in non-human living tissue. For example, potential pathogens from swine range from organisms likely to cause disease in immunocompromised transplant recipients to pathogens known to infect pigs. In addition to concerns about transplant patients themselves, public health concerns center on the possibility that infections could by transmitted by xenograft recipients to the general population. Unfortunately, there are not enough data to adequately quantify these risks.

What are the key principles for preventing surgical site infections?
Preoperative:

Tobacco cessation at least 30 days prior to elective surgery

Antimicrobial prophylaxis

Use the correct agent for the type of operation

Administer 30 to 60 minutes prior to incision

Readminister if surgery is delayed beyond 1 hour after the first dose

Maintain at therapeutic levels throughout surgery

Discontinue no later than 24 hours after the end of surgery

Preoperative showering with chlorhexidine gluconate 4% solution the night before surgery

No hair removal or, if hair removal is necessary, clipping immediately prior to surgery

Preoperative skin antisepsis with an effective, broad-spectrum, fast-acting antimicrobial with persistent effects, such as 2% chlorhexidine gluconate with 70% isopropyl alcohol Prevention and Treatment of Surgical Site Infection Essay Paper

Preoperative scrubbing of arms and hands for at least 5 minutes prior to surgery and between 2 and 5 minutes for each subsequent procedure

Perioperative:

Prevent intraoperative hypothermia

Monitor and control glucose levels at HbA1c <7%

Consider supplemental oxygen to prevent perioperative hyperoxia

Pack contaminated abdominal wounds and evaluate for signs of infection before closing

What are the consequences of not working to prevent surgical site infections?
Patients with SSI are twice as likely to die, 60% more likely to be admitted to the intensive care unit, and more than five times more likely to be readmitted to the hospital after discharge

Onset of an SSI is estimated to increase a hospital stay by 7 to 10 days and add over $3,000 in costs of care

Types of surgical site infections
An SSI typically occurs within 30 days after surgery. The CDC describes 3 types of surgical site infections:

Superficial incisional SSI. This infection occurs just in the area of the skin where the incision was made.

Deep incisional SSI. This infection occurs beneath the incision area in muscle and the tissues surrounding the muscles.

Organ or space SSI. This type of infection can be in any area of the body other than skin, muscle, and surrounding tissue that was involved in the surgery. This includes a body organ or a space between organs.

Signs and symptoms of surgical site infections
Any SSI may cause redness, delayed healing, fever, pain, tenderness, warmth, or swelling. These are the other signs and symptoms for specific types of SSI:

A superficial incisional SSI may produce pus from the wound site. Samples of the pus may be grown in a culture to find out the types of germs that are causing the infection.Prevention and Treatment of Surgical Site Infection Essay Paper

A deep incisional SSI may also produce pus. The wound site may reopen on its own, or a surgeon may reopen the wound and find pus inside the wound.

An organ or space SSI may show a discharge of pus coming from a drain placed through the skin into a body space or organ. A collection of pus, called an abscess, is an enclosed area of pus and disintegrating tissue surrounded by inflammation. An abscess may be seen when the surgeon reopens the wound or by special X-ray studies.

Causes and risk factors of surgical site infections
Infections after surgery are caused by germs. The most common of these include the bacteria Staphylococcus, Streptococcus, and Pseudomonas. Germs can infect a surgical wound through various forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through germs in the air, or through germs that are already on or in your body and then spread into the wound.

The degree of risk for an SSI is linked to the type of surgical wound you have. Surgical wounds can be classified in this way:

Clean wounds. These are not inflamed or contaminated and do not involve operating on an internal organ.

Clean-contaminated wounds. These have no evidence of infection at the time of surgery, but do involve operating on an internal organ.

Contaminated wounds. These involve operating on an internal organ with a spilling of contents from the organ into the wound.

Dirty wounds. These are wounds in which a known infection is present at the time of the surgery.

These are other risk factors for SSIs:

Having surgery that lasts more than 2 hours

Having other medical problems or diseases

Being an elderly adult

Being overweight

Smoking

Having cancer

Having a weak immune system

Having diabetes

Having emergency surgery

Having abdominal surgery

Helping prevent surgical site infections
If you are having surgery, ask your doctor what you can do to reduce your risk for a surgical site infection. It’s important to stop smoking before surgery and to tell your surgical team about your medical history, especially if you have diabetes or another chronic illness. Also, avoid shaving in the skin area that the surgeon is planning to operate through.Prevention and Treatment of Surgical Site Infection Essay Paper

No matter how curious they are, loved ones should not touch your wound or surgical site. Carefully follow your doctor’s instructions about wound care after surgery. Call your doctor if you develop a fever or pus, redness, heat, pain or tenderness near the wound or any other signs or symptoms of a surgical site infection.

Treating surgical site infections
Most SSIs can be treated with antibiotics. Sometimes additional surgery or procedures may be required to treat the SSI. During recovery, make sure that friends and family members wash their hands before and after they enter your room. Make sure doctors, nurses, and other caregivers wash their hands, too.Prevention and Treatment of Surgical Site Infection Essay Paper

Health care-associated infections (HCAIs) are infections that are acquired through contact with any aspect of health care. They can cause minor complications or serious disability or death, and can involve a wide variety of resistant or emergent organisms.1 Examples of HCAIs include respiratory tract infections such as hospital- and ventilator-associated pneumonias complicated by Gram-negative, nonfermenting bacilli that are resistant to almost all classes of antibiotics; and urinary tract infections caused by microorganisms resistant to the quinolones and increased by the presence of a catheter, mostly involving coliforms that can produce extended spectrum beta-lactamases (and, more worryingly, metallo-beta-lactamases, such as the newly described New Delhi-metallo-beta-lactamase 1 [NDM-1],2,3 making bacteria resistant to a wide range of beta-lactam antibiotics, including all carbapenems). Infections involving prosthetic materials, as diverse as hip replacement or vascular grafts, are caused mainly by multiple-resistant coagulase negative staphylococci; bacteraemias and complicated skin and soft tissue infections are associated with highly virulent meticillin sensitive Staphylococcus aureus (MSSA) or meticillin resistant Staphylococcus aureus (MRSA) strains; and emergence of Clostridium difficile is the underlying cause of antibiotic related colitis.4 Among HCAIs, surgical site infection (SSI) is of greatest recent concern.5 Surgical site infections can be caused by many organisms which may be antibiotic resistant. Patients who develop HCAIs usually have related treatments or underlying contributory illnesses, but the misuse of antibiotics is a key factor in all cases. All HCAIs can be prevented or reduced by attention to known risk factors. The cost of HCAIs to health care is large,6,7 and has prompted many initiatives associated with extensive international media and political campaigns. The bacteria involved in SSIs include those carried by the patients themselves (endogenous flora), and those that may be introduced in the operating room (exogenous flora).5 Native colonization (the source of infection), is determined through the type of surgery (eg, coliforms and anaerobes in colorectal surgery), although staphylococci predominates overall from the bacterial reservoir in skin. Gram-positive pathogens from airborne microbes and the surgical team (due to glove punctures during surgical procedures or from suboptimal sterilization of instruments) may be infrequent sources of contamination of the surgical site. Opportunistic and resistant organisms may be cultured from infections after selected operations (eg, prosthetic surgery). All patients are at risk of acquiring resistant organisms, particularly if they have an underlying debilitating illness, poor compliance with accepted prevention guidelines, or they have health care-associated exposure (ie, prior hospitalization or admission to a chronic care facility) that colonizes them with unusually resistant bacteria. Surgical site infections make up approximately a fifth of the HCAIs in the United Kingdom, and at least 5% of patients undergoing open surgery in the UK develop an SSI.8 Surgical site infections are probably the most preventable HCAI but have received the least attention; although that is changing with increased surveillance and public awareness of published data of individual specialty and hospital incidence rates.9-11 Surgical site infections are associated with more than one-third of postoperative related deaths ranging from relatively trivial, short-lived, wound discharge (eg, after open hernia surgery) to being life threatening (eg, mediastinitis and sternal wound infection).12 In between, HCAIs contribute to scars which may be cosmetically unacceptable to the patient, cause pain, require prolonged length of hospital stay with the incurred expenses, and result in poor emotional well-being for the patient.Prevention and Treatment of Surgical Site Infection Essay Paper

Surgical Site Infection
Definitions. Many surgeons are unaware of their SSI rate because of nonexisting or suboptimal surveillance and inconsistent definitions. The first realistic survey of SSI was not sensitive, as only the presence of pus was used for the identification of SSI.14 Wounds are now categorized into clean (no viscus opened), clean-contaminated (viscus opened, minimal spillage), contaminated (viscus opened with spillage or presence of inflammatory disease), and dirty (pus or perforation present or incision made through an abscess).15 This categorization was based on a theoretical division of potential for SSI development. It is flawed by the failure to include patient risk and the use of prosthetic materials, which may dramatically impact the risk for SSI in procedures within the clean category. Furthermore, because of the constant introduction of new operative techniques, particularly endoscopic procedures and the rise of natural orifice transluminal endoscopic surgery (NOTES) this categorization is becoming increasingly blurred and may not be applicable. It is critical that standard definitions are used to allow studies to be comparable. Analysis of outcomes and comparison between studies requires exact definitions of patients’ characteristics and their risk stratification, based on comorbid medical conditions. In addition to demographic details, clinical manifestations of SSI vary epidemiologically depending on the onset of infection. The Centers for Disease Control and Prevention (CDC) is the most widely used and comprehensive definition (Table 1).16 This system only gives categorical data which does not reflect the severity of an SSI. In brief, SSIs are categorized at 3 levels: superficial incisional, in the skin or subcutaneous tissues; deep incisional involving fascia or muscle; and deep/organ space, involving, for example, the pleura after lung surgery or the liver after hepatic resection. Most SSIs fall into the superficial group and the less common deep/organ space infections are the most serious or life threatening. The categories are open to interpretation and may depend on the attending physician’s diagnosis. By contrast, the ASEPSIS scoring method for postoperative wound infections gives interval data17 but, despite its simplicity, has only been used in research trials. In today’s world of same-day surgery and fast-track postoperative recovery ASEPSIS is less easy to use and its validity may be questioned.18 Surveillance, incidence, and cost. Surveillance is equally critical to standard definitions. The CDC definition requires surveillance for infection be undertaken for 30 days for infection in soft tissues and up to a year for orthopedic and vascular prosthetic surgery. Again, the uptake of same-day surgery and fast-track postoperative recovery has affected the accuracy of surveillance figures, which were largely based on inpatient data. Postdischarge surveillance must now be included since the majority of SSIs have a mean time to presentation of 8-10 days and are not apparent until after the patient has left the hospital. Ideally, surveillance should include a trained, blinded observer using agreed-upon definitions rather than surrogate automated methods.18-24 Accurate surveillance, including postdischarge data, can inform and influence practice by allowing valid comparisons.25,26 In some countries, SSI surveillance is becoming mandatory. The methodology used has to be pragmatic and mostly depends on assessment at discharge, or telephone and questionnaire follow-up, but in research trials individual follow-up by direct observation is required for accuracy. Some areas of surgery have a low incidence of SSI, such as laparoscopic/endoscopic surgery.27 There have been several predictive indices for SSI. The Study on the Efficacy of Nosocomial Infection Control (SENIC) included contaminated wound, diagnosis at discharge, duration of surgery, and abdominal surgery; and the National Nosocomial Infections Surveillance index included contaminated wound, the American Society of Anesthesiologists Physical Status classification system grade, and duration of surgery. They have been compared28,29 and both were found capable of predicting SSI. Apart from the unrecorded indirect costs related to loss of productivity, reduced quality of life, and litigation, the actual cost of an SSI can involve additional inpatient treatment and procedures that can run into many thousands of pounds.30 The morbidity and mortality rates which follow sternal infection after cardiac surgery are just one example.31 There is a paucity of prospective cost-benefit analysis of the SSI, but retrospective analyses clearly identify that the economic costs of SSI are substantial.Prevention and Treatment of Surgical Site Infection Essay Paper

Prevention of Surgical Site Infection
Level I evidence. Many national and international guidelines present the best available evidence for the prevention of SSI. In the United Kingdom, for example, there are 2: from the National Institute for Health and Clinical Excellence (NICE)33 and the Scottish Intercollegiate Guideline Network (SIGN).34 In the United States, similar quality improvement programs include the Surgical Care Improvement Project (SCIP)35 and the National Surgical Quality Improvement Program (NSQIP).36,37 The principal recommendations have been collated into a care bundle by the Department of Health of the United Kingdom.38 The concept of using this best evidence should summate the effects of the interventions, but success depends on the quality of compliance. The longer-term follow-up of NICE, SCIP, and NSQIP and their respective degree of compliance, will determine how effective they are. The effectiveness of these national guidelines and performance measures to improve the rates of SSI remains to be seen. Three recent studies have demonstrated no improvement in SSI rates despite national efforts in the US to enforce compliance with SCIP measures.39-41 Hospitals with high rates of compliance do not have better SSI rates than those with less compliance. It is important to emphasize that SSI rates are influenced by multiple clinical variables and not only those articulated by national agencies. The recommendations by NICE and SCIP are clinically valid, but issues such as poor surgical technique and suboptimal compliance, along with the many other variables that influence SSI, will negate the benefits that should be seen. Clinicians and government policy makers must understand the complexity of SSI as a clinical outcome; recommendations focused upon a limited number of practices are only a starting point in prevention and, by themselves, may not influence overall outcomes.42 Common to all of the guidelines and performance measures is the level I evidence supporting the rational use of antibiotic prophylaxis and the avoidance of razors for hair removal. Considerable level I evidence shows antibiotic prophylaxis significantly reduces SSIs after clean prosthetic, clean-contaminated, and contaminated operations.33-38 Prophylaxis should be initiated within the immediate preincisional period of time (< 60 minutes before incision) and the antibiotic that is chosen should cover the organisms that are likely to be encountered. The selected antibiotic may depend on local resistance patterns, and guidance of a local formulary may be necessary. Usually a single-dose of antibiotic at, or immediately before, the induction of anesthesia is sufficient. Dirty operations, where infection already exits, will need a longer course of antibiotics that acts both as therapy and prophylaxis. During the past 3 decades, prevention of SSI has relied almost entirely on the availability of effective perioperative antibiotic prophylaxis due to its high level of evidence. For the same reason, antibiotic prophylaxis has also been used for treatment of infections after clinical presentation. For example, in vascular surgery, 10 randomized controlled trials (RCTs) have been undertaken comparing systemic antibiotics vs placebo, and a systematic review and meta-analysis43 demonstrated a consistent benefit in reduction of SSI in 1297 patients relative risk (RR fixed, 0.25; (95% CI, 0.17 to 0.38; P = 0.0001). Although no single study demonstrated a statistically significant reduction in early vascular graft infection, the pooled results of these 10 RCTs appeared homogeneous with a reduction in early graft infection evident on meta-analysis (RR fixed, 0.31; 95% CI, 0.11 to 0.85; P = 0.02). There are, however, 2 aspects of these results which need to be highlighted. First, 6 of the 10 RCTs included a case-mix of patients with both prosthetic and vein grafts. If the results of the prophylactic effect of antibiotics are stratified by the type of graft, the RR for wound infection with prosthetic graft is nonsignificant at 0.51 (95% CI, 0.24 – 1.11). The administration of prophylactic antibiotics yielded a significant benefit only for patients with vein grafts (RR = 0.13; 95% CI, 0.04 – 0.41). Therefore, in vascular surgery, evidence for the prophylactic effect of systemic antibiotics exists only for patients with vein grafts, who are at lower risk of infection, compared to patients receiving prosthetic material. Second, the meta-analysis is based on 10 studies that compared the effect of systemic antibiotics with placebo, conducted in the early to mid-1980s. Resistance of Staphylococcus aureus (the most frequent bacterial organism to cause vascular infections) to methicillin was first noted clinically in 1961.44 In the US, methicillin-resistant Staphylococcus aureus (MRSA) only emerged in the period 1975 to 1981 in tertiary care centers. The percentage of major US acute care hospitals reporting greater or equal to 50 MRSA cases per year increased from 18% in 1987 to 32% in 1989.45 Therefore, the result of meta-analyses of RCTs chiefly investigating the beta-lactam antibiotics which demonstrated efficacy of antibiotic prophylaxis need to be noted with caution today, as MRSA already has become the most frequent cause of skin and soft tissue infections presenting to emergency departments in the US.46 Although speculative, it remains questionable if a meta-analysis of these RCTs would yield significance again if conducted with the current rigor and epidemiologic situation. The studies which give evidence that the use of razors to remove hair preoperatively cause infection are primarily from 30 years ago, but most guidelines suggest that if hair has to be removed, it should be done with a disposable clipper head, close to the time of surgery.33,47 These studies are robust enough to give level I evidence. The damage caused to skin by shaving too long before surgery encourages the growth of organisms, which increase the risk of SSI. Also common in the guidelines and performance measures are methods to optimize the physiology of the host at the time of the operations; that is, avoidance of hypothermia, adequate glycemic control, and supplemental oxygen administration. The clinical value of avoiding perioperative hypothermia was first realized more than 15 years ago48 and there has since been many adequate RCTs confirming the relevance of warming in the prevention of SSI,23 which led to a NICE guideline.49 The pathophysiological benefit has also been well examined.50 From the analysis of secondary outcomes in clinical trials, it has been suggested that patients who have diabetes and whose blood sugar is out of control are more at risk of SSI. This is supported by experimental evidence that many physiological mechanisms are impaired by hyperglycemia. Most guidelines suggest blood glucose should be tightly controlled in patients with diabetes.38 However, it has been convincingly shown that following cardiac surgery, even in patients without diabetes, poor glucose control is associated with poor wound healing, as well as SSI in sternal wounds and in leg wounds after harvest of saphenous vein.51 The maintenance of blood glucose has been adopted as standard practice in cardiac surgery and it is unlikely that RCTs will be undertaken to further prove this point. However, glycemic control in other fields of major surgery remains unproven, and tight glycemic control in patients without diabetes remains an area to be explored with RCTs. This may be especially true in trauma patients and patients with major surgical interventions, where hyperglycemia is part of the normal metabolic response to trauma and major surgical stress. Intraoperative and immediate postoperative use of supplemental oxygen in the prevention of SSI discussed in this review because of the conflict in the results of RCTs. Considerable experimental evidence supports the use of supplemental oxygen to prevent incisional infection.52 Two RCTs have demonstrated significant reductions in SSI by the use of intraoperative and immediately postoperative oxygen supplementation (FiO2= 0.8).53,54 A single RCT has demonstrated an increase in SSI rates with supplemental oxygen.55 While the theoretical arguments to support supplemental oxygen are abundant, additional studies appear to be warranted before guidelines or performance measures can be applied for the prevention of SSI. Other evidence and risk factors. Many guidelines and reviews have listed other factors (Table 2) that can influence the incidence of SSI but most are of level II evidence base at best.56,57 Many are anecdotal, others have been identified by logistic regression analysis in trials and audit of SSI; and others by meta-analysis (Table 1). Many of these reports suggest that being male or being elderly is associated with an increased risk of SSI, although 1 cohort study found a decreasing risk after 65 years.58 Obesity is also cited in studies as being an important, independent risk factor.23,33 In addition, many patient-related factors, including smoking, have a strongly supportive experimental base which has not been proven conclusively in clinical trials. This also applies to immunosuppressive, nutritional, and metabolic factors outside the scope of this article. Serum albumin is an example of a factor often ascribed significance for being an independent clinical risk factor, but it has not been clearly defined as such in prospective trials. A low value is associated with uncertain causation and may not reflect nutritional deficiencies in the developed world. However, experimental data shows it is a strong marker of poor healing; but in clinical practice, the serum albumin value is usually related to confounding factors associated with severe systemic illness, such as cancer cachexia or sepsis. The NSQIP places emphasis on low albumin being a predictor of surgical complications, but only further prospective studies will confirm its true role as a predictor of SSI. Nasal decontamination (suppression) of Staphylococcus aureus was introduced by infection prevention programs in an effort to reduce the risk of MRSA. Both MSSA and MRSA can cause SSI, and staphylococci remain overall the commonest infecting organisms. Nasal suppression has not been recommended by NICE or SCIP to reduce SSI, but there is now evidence that this is useful; it is important to remember that MSSA infections are just as important to prevent.59 Mechanical bowel preparation has been the subject of a meta-analysis showing it does not reduce the risk of SSI.60 However, this finding, like many Cochrane Collaboration meta-analyses, needs clinical interpretation prior to implementation for all patients. Since the 1930s, it has been shown that mechanical bowel preparation alone does not reduce SSI rates.61 Mechanical preparation with the use of orally-administered and poorly absorbed antibiotics (eg, neomycin and erythromycin) has been shown in prospective, randomized, placebo-control trials to reduce SSIs.62,63 Two separate meta-analyses show that mechanical bowel preparation, when combined with the oral antibiotic bowel preparation and systemic prophylactic antibiotics, do reduce SSI in elective colon resection when compared to mechanical bowel preparation and systemic antibiotics only.64, 65 Skin preparation is routine prior to surgery but there has been little clear evidence demonstrating which antiseptic preparation is the best. Chlorhexidine has been a popular skin preparation, but in a concentration of 2% in combination with 70% isopropanol it has been shown to significantly reduce superficial and deep SSIs.66 The use of topical antiseptics for preparation of the surgical team’s hands, and as a preoperative wash for patients, has a good evidence base which deserves recognition.67-69 In view of the continued rise of antibiotic resistance, the use of antiseptic dressings and prophylactic antiseptic lavage for wounds and cavities bears reconsideration in future clinical trials, as well as reconsideration as a treatment for established SSIs.33,57 Intraoperative factors that might relate to the incidence of SSI are traditionally observed and operating room discipline is long established, with a reluctance to change protocol without clear evidence. Operating room environment control has to be placed in this category. Some of these factors do have basis and are included in the risk factor prediction indices.28,29 The NICE guideline, having reviewed the old trials33 of antiseptic impregnated drapes, recommended they be used as nonimpregnated drapes, as there clearly was an increased risk of SSI associated with their use. By contrast, the guideline could not recommend, for example, the use of diathermy to reduce the risk of SSI. Evidence that the use of antimicrobial sutures can reduce SSIs is increasing; this has been found in clean, prosthetic, abdominal and thoracic surgery,18,57,70-73 and a meta-analysis has now been published which shows a level I evidence-base of the efficacy of antimicrobial sutures for the prevention of SSI.74 Again, we are seeing the return of antiseptics as a first line treatment of managing SSI. Many of the remaining factors listed in Table 1 have been challenges, although many of them are part of the traditional lore of clinical surgery. Guidelines continue to support gowns and drapes, appropriate use of surgical gloves, and reduction of movement in the operating room. Some have advocated the banning of jewelry and nail polish, but the evidence to support these policies are lacking. Preoperative showering and the value of wound drains are areas with supportive opinions but need additional research to validate their application. Other strategies used in infection prevention, such as maximal sterile barrier precautions; routine change of surgical gloves before graft implant; performing surgical procedures in HEPA filtered, turbulence-free, laminar air-flow, ventilated operation rooms; implementation of perioperative surgical check lists; or the choice and concentration of pre-operative skin antiseptics and how they should be used, have not been studied in depth and indicate areas for future research.Prevention and Treatment of Surgical Site Infection Essay Paper

Treatment of Established Surgical Infection and SSIs
Essential to treating surgical infection, and superficial and deep SSIs, is to open the area of infection and to drain pus. With deep SSI, this may require opening and draining the entire incision, while superficial SSI may only require a limited area of drainage. Fibrinous debris is removed and any remaining sutures or staples in the area of infection should also be removed. The open wound commonly needs specific wound care to allow healing by secondary intention, although delayed primary or secondary closure may be feasible in selected cases. The open wound is managed with interactive moist dressings and wound desiccation should be avoided. The use of topical antimicrobial therapy is largely chosen by physician preference and remains an area for additional comparative investigations of alternative agents. The concerns that antiseptics may induce bacterial resistance to themselves, or even to antibiotics, with the risks of transmission, are unfounded. This is either because their mode of action is not suitable for bacteria to develop resistance, or because the clinically used high concentrations of antiseptics (which often surpass the required minimum inhibitory concentrations by 500 to 1,000 fold), are still able to rapidly kill off pathogens even if they have developed a decreased susceptibility against the applied antiseptic.74 Topical negative pressure wound management may be desirable in specific cases, but most superficial and deep SSIs do not require antibiotics when drainage and debridement is prompt. Antibiotics are warranted when local cellulitis or wound necrosis is present (Table 3). For staphylococcal SSI, microbiological culture and sensitivities may be needed to direct antibiotic coverage for MSSA or MRSA. With community-associated MRSA, clindamycin, trimethoprim/sulfamethoxazole, or doxycycline may be sufficient. Clinicians are advised to beware the clindamycin-sensitive but erythromycin-resistant MRSA since many of these organisms develop induced resistance to clindamycin during therapy. For conventional health care-associated MRSA, the use of vancomycin, linezolid, or daptomycin may be appropriate. Gram-negative infections need culture guidance, and when infections follow colonic procedures, the coverage of enteric anaerobic species, with use of metronidazole for example, is necessary. The organ/space infection may require more aggressive measures. When there is necrotizing infection and separation of the fascia, debridement is essential. Debridement of these infections can be extensive with considerable loss of fascia and associated muscle. Invasive necrotizing infections within the surgical incision have become an increasing problem with the community-associated MRSA pathogens.75 Polymicrobial necrotizing infections will be seen following gastrointestinal contamination of the surgical site. Inadequate debridement leads to additional debridement and increased fascia and muscle loss. Temporary absorbable meshes may be required for abdominal wounds when there is loss of fascia. High rates of ventral hernia are seen following the scenario of necrotizing infection and absorbable meshes in the abdominal wall. Intra-abdominal abscesses may require percutaneous drainage procedures. Management of the source of the organ/space infection, such as a leaking intestinal suture line, may require surgical management to control the source of continued contamination. Infected prostheses generally require removal, although these infections of vascular grafts, heart valves, and prosthetic joints pose special problems. Antibiotics are almost always required for organ/space infections, the specific choice of which must be guided by culture and sensitivity data. Organ/space SSI pathogens are often staphylococcal but these infections are commonly associated with resistant organisms from the hospital environment. Antibiotic therapy again must be driven by specific culture and sensitivity data.

Microbiological Diagnosis
Microbiological investigations may support the diagnosis of SSI and surgical infections, provided specimens are obtained appropriately. Thereby, microorganisms that are potentially causative for infection are yielded, and not colonized flora, which have no relevance for a suspected infection. Optimal results are achieved from specimens obtained directly from the infection site. Such material may include explanted grafts, extra- or intra-operatively obtained tissue biopsies from the infected area, and material aspirated from peri-graft fluid collection. Indirectly obtained material, such as blood cultures, may also yield important information. However, blood cultures may often be negative, particularly in late-onset infection, but are more frequently positive in early-onset infection.76 Specimens may be processed using a number of techniques such as direct streaking swabs on agar plates, broth culture, homogenization of tissue specimens with serial dilution techniques, and sonication of the specimen to enhance the recovery of biofilm-forming organisms from graft or infected material.77 The report of processed microbiological specimens is decisive for a valuable evaluation of therapy and clinical results.78,79 The demonstration of specimens’ relevance from the pre-, intra- and postoperative phases is considered most valuable, if feasible and possible.80 Relevant preoperative samples include blood cultures taken from central and peripheral venous catheters or direct vein puncture, wound specimens, drainage fluid, nose and throat swabs in the case of MRSA colonization, and urinary samples. In any case, all responsible microorganisms should be classified according to their type (eg, Gram-positive or -negative, fungi, etc.) and specific therapy antibiograms offered for highly virulent microorganisms (eg, Pseudomonas aeruginosa). Careful assessment is needed for microorganisms isolated from overlying wounds or sinuses, as such microorganisms may represent colonizing flora, (eg, MRSA), and may be wrongly interpreted as causative agents.76 Relevant intraoperative samples are standard specimens obtained from the surgical site, the peri-graft fluid/pus, or explanted prosthetic material. Worth noting is that a considerable number of specimens may be negative.81-83 A negative microbiological report, however, does not exclude an infection. Finally, relevant postoperative samples are blood cultures, drainage fluid, and wound specimens (eg, those usually taken when there is delayed wound healing). The development of polymerase chain reaction methodologies that will provide unique bacterial species and sensitivity signatures may greatly enhance the diagnosis of infection and will reduce the number of circumstances where microbiological evaluation of wound and blood cultures are negative, but clinical infection appears to be present   Prevention and Treatment of Surgical Site Infection Essay Paper

Centers for Disease Control and Prevention (CDC) definition for wound class and classification of SSI were used. Surgical site infection (SSI) was defined as an infection occurring within 30 days of the operative procedure, with the patient having one or more of the followings: (i) purulent drainage from the surgical incision; (ii) organisms isolated from an aseptically obtained culture of fluid or tissue from the surgical incision; (iii) at least one of the following: pain or tenderness, localized swelling, redness, or heat. SSIs were classified as being incisional, deep incisional or organ/space. A surgical procedure was defined as the single surgery that was performed in the operating theatre. If more than two surgical procedures were performed in a single patient, the characteristics of the first surgical procedure were described.

Data collection
Clinical data on HIV-infected patients undergoing surgery from October 2008 to September 2011 were retrieved using our computerized patient record system. Inclusion criteria: HIV-infected patients were identified and diagnosed by local Centers for the Disease Prevention and Control in different places. HIV test was done using ELISA and Western blot. Upon admission, all selected patients had records containing information on thorough disease histories, physical examinations, preoperative and postoperative routine examination, and immune function tests.

Patient group and study methods
A retrospective study of SSI was conducted in 242 HIV-infected patients including 17 patients who combined with hemophilia from October 2008 to September 2011 in Shanghai Public Health Clinical Center. SSI were classified according to Centers for Disease Control and Prevention (CDC) criteria and identified by bedside surveillance and post-discharge follow-up. We stratified and compared the incidence of SSIs according to preoperative CD4 counts with breakpoint values of 200 and wound class. Patients combined with hemophilia were divided into SSIs group (A) and no-SSIs group (B). Demographic and clinical information was entered into a database that included: type of surgical procedure, age, peripheral blood cells, plasma albumin, CD4 counts, and CD4/CD8 ratios.Prevention and Treatment of Surgical Site Infection Essay Paper

Our study was a retrospective study conformed to the tenets of the Declaration of Helsinki. It had been approved by Institutional Ethics Review Board of Shanghai Public Health Clinical Center (International index IORG0006364).

Statistical analysis
Data were analyzed using SPSS 16.0 statistical software (SPSS Inc., Chicago, IL). Results of all continuous data are presented here as mean ± standard deviation. Continuous variables were compared with independent t-test. Univariate analysis of the categorical outcome was carried out using Chi-squared tests. P<0.05 indicates statistical significance. Prevention and Treatment of Surgical Site Infection Essay Paper