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The evidence-based way to prevent wound infections

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References

Prophylactic intranasal mupirocin reduced infection risk in cardiothoracic patients,7 but preoperative use did not reduce gram-positive SSI rates in digestive tract surgery.8

Mupirocin also failed to reduce the wound rates in patients who had a variety of procedures, although the rate of nosocomial S aureus infections in the subset of patients with nasal colonization was reduced.9

Topical microbicides

Soap-and-water washing removes most debris from skin or other surgical surfaces, but antiseptic solutions reduce resident skin flora populations. The choice of appropriate topical microbicides during surgery can influence SSI rates (EVIDENCE CATEGORY IB).

When selecting an antiseptic, consider the anticipated duration of the case, the epithelial surface to be breeched (mucous membrane vs keratinized skin), and the anticipated flora.

CDC ADVISORY

Best practices for preventing surgical site infections

Recommended for all hospitals

EVIDENCE CATEGORY IA—Well-designed studies

  • Cancel elective surgery if the patient has a remote infection
  • Achieve maximal subcutaneous concentration of preoperative antibiotics
  • Avoid routine vancomycin and similar agents
  • Maintain prophylactic antibiotics for only a few hours after closing incisions
  • For high-risk cesarean, administer the prophylactic antimicrobial immediately after the umbilical cord is clamped
  • If it is necessary to remove hair, use clippers, not shaving, immediately before the operation.

EVIDENCE CATEGORY IB—Good evidence and expert consensus

  • Control glucose levels and avoid perioperative hyperglycemia
  • Encourage patients to quit or minimize smoking
  • Require the patient to shower or bathe with an antiseptic agent
  • Surgical hand hygiene to include scrub to elbows for 2- to 5-min, use sterile towel, keep fingernails short, clean under fingernails
  • Use appropriate topical microbicides during surgery
  • Pay careful attention to proper surgical technique

We still don’t know

NO RECOMMENDATION; UNRESOLVED ISSUE—Evidence is insufficient

  • Enhance nutritional support solely to prevent SSI?
  • Discontinue or taper steroids if medically permissible?
  • Measures to enhance wound space oxygenation?
  • Preoperatively apply mupirocin to nares?

The complete Guideline for Prevention of Surgical Site Infections is available online at www.cdc.gov/ncidod/hip/SSI/SSI_guideline.htm.1

Shaving and hair removal

Hair removal is often necessary, but shaving may cause skin trauma that exacerbates bacterial growth.10 SSI rates correlate with the time interval between shaving and incision (20% if shaved >24 hours before surgery, 7.1% the night before, and 3.1% in the OR).11 Thus, the CDC guidelines discourage shaving prior to surgery (EVIDENCE CATEGORY IA).Patients have been known to shave the operative area themselves before surgery, so all patients must be told not to shave themselves before elective surgery.

When hair removal is necessary, preoperative clipping causes minimal skin trauma (EVIDENCE CATEGORY IA).

Preparing The Surgical Staff

The surgeon’s hands

Evidence has shown that 2 minutes of preoperative scrubbing reduces resident flora as effectively as scrubbing for 10 minutes.1 The recommended scrub should include hands and forearms up to the elbows for 2 to 5 minutes (EVIDENCE CATEGORY IB).

Keep hands away from the body and dry hands with a sterile towel (EVIDENCE CATEGORY IB).

Keep fingernails short (EVIDENCE CATEGORY IB), and clean under each nail at the beginning of each day (EVIDENCE CATEGORY II).

An aqueous alcohol solution is a recent alternative to traditional hand antisepsis with chlorhexidine- or povoidoneiodine–based solutions. No difference in SSI rates has been documented between hand-rubbing with an aqueous alcohol solution and traditional scrubbing.12 A traditional scrub before the first of consecutive cases and after contact with gross contamination is still in order.

Sterile barriers

Sterile barriers in the operating room, indispensable in protecting staff, are federally mandated. Their role in preventing SSI is not clear. Surprisingly, the use of face masks may not contribute to SSI reduction.13 Head covering, on the other hand, markedly reduces airborne and wound bacterial contamination.14

Optimize Wound Physiology

Maintaining normothermia

Hypothermia is common, particularly in patients who are immunocompromised, at age extremes, or have multiple trauma. Hypothermic vasoconstriction may reduce tissue perfusion and increase risk of infection.

A double-blind study showed that maintaining intraoperative normothermia decreased SSI in colorectal patients from 19% to 6%.15 Additionally, preoperative warming of the entire body or local site for 30 minutes reduced SSI rates in clean surgical cases.16

Wound space oxygenation

Supplemental oxygen in colorectal surgery may correlate with lower infection rates (80% without supplemental oxygen, 30% with).17 This may improve tissue oxygen tension, which enhances oxidative bactericidal capacity.

However, these findings were not duplicated in patients with higher SSI rates and on supplemental hyperoxia.18 There are no recommendations for enhancing wound space oxygenation.

Control of glycemia

Cardiothoracic surgery studies have stressed the importance of tight perioperative glycemic control. Coronary artery bypass patients with higher mean perioperative glucose showed a trend toward a higher risk of nosocomial infection, but not specifically SSI.19 Another study of cardiothoracic patients found an association between higher risk of SSI and both diabetes and postoperative hyperglycemia.20 Continuous intravenous insulin to maintain a blood glucose 21

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