Surgical Site Infections
By Vickie VanDeventer, RN, BSN, CIC
This article highlights a few guidelines from The Recommendations for Prevention of Surgical Site Infection, 1999 created by the Hospital Infection Control Practices Advisory Committee.
Twenty-seven million surgical procedures are performed in the US each year. Surgical Site Infections (SSIs) are the third most common nosocomial infection (14-16%) among hospitalized patients. Among surgical patients, SSIs are the most common nosocomial infection, accounting for 38% of infections. The definitions used to determine SSIs must be standardized and consistent. The Centers for Disease Control and Prevention (CDC) has developed standardized criteria for defining SSIs (seeTable 1, below). The National Nosocomial Infections Surveillance (NNIS) Report was established in 1970. This is a database that gives us national infection rates. We can use this database to compare our infection rates to see if we are within acceptable limits.
The most common organisms isolated from SSIs have not changed. We continue to see Staphylococcus Aureus as the most common organism, followed by Coagulase-negative staphylococci, Enterococcus species, and Escherichia coli. We have recently seen an increase in SSIs caused by antimicrobial-resistant pathogens, such as Methicillin Resistant Staphylococcus Aureus (MRSA). For most SSIs, the source of the pathogens is from the skin flora, mucous membrane, or hollow viscera of the patient. A "risk factor" is a variable that has a significant, independent association with the development of an SSI. Knowledge of risk factors before certain operations may allow for prevention measures to be done. Host-related risk factors include: age, nutritional status, diabetes, smoking, obesity, infection at a remote body site, colonization with microorganisms, altered immune response, and length of preoperative stay. Procedure-related risk factors include: duration of surgical scrub, skin antisepsis, preoperative shaving, preoperative skin prep, duration of operation, antimicrobial prophylaxis, operating room ventilation, inadequate sterilization of instruments, foreign material in the surgical site, surgical drains, and surgical techniques.
A "prevention measure" is an action or set of actions taken to decrease the risk of an SSI. The Recommendations for Prevention of Surgical Site Infection, 1999 provides us with prevention measures we can take to decrease SSIs in hospital facilities. These guidelines represent the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC). The guideline rankings are as follows:
Category IA: Strongly recommended for implementation and supported by well-designed, experimental, clinical, or epidemiological studies.
Category IB: Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and strong theoretical rationale.
Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale.
No recommendation: unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.
The following are the recommendations in Categories IA and IB. These guidelines cover the Preoperative Characteristics, Intraoperative, and Postoperative Incision Care.
Preparation of the patient. Whenever possible, identify and treat all infections remote to the surgical site before elective operations and postpone elective operations on patients with remote site infections until the infection has resolved (IA). Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation (IA). If hair is removed, remove immediately before the operation, preferably with electric clippers (IA). Adequately control serum blood glucose levels in all diabetic patients and particularly avoid hyperglycemia perioperatively (IB). Additionally, encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before elective operation from smoking cigarettes, cigars, pipes, or any other form of tobacco consumption (IB). Do not withhold necessary blood products from surgical patients as a means to prevent SSI (IB). Require patients to shower or bathe with an antiseptic agent on or at least the night before the operative day (IB). Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation (IB). Use an appropriate antiseptic agent for skin preparation (IB).
Hand/forearm antisepsis for the surgical team members. Keep nails short and do not wear artificial nails (IB). Perform a preoperative surgical scrub for at least two to five minutes using an appropriate antiseptic. Scrub the hands and forearms up to the elbow (IB). After performing the surgical scrub, keep hands up and away from the body (elbows in flexed position) so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and don a sterile gown and gloves (IB).
Management of infected or colonized surgical personnel. Educate and encourage surgical personnel who have signs and symptoms of a transmissible infectious illness to report conditions promptly to their supervisory and occupational health service personnel (IB). Develop well-defined policies concerning patient-care responsibilities when personnel have potentially transmissible infectious conditions. These policies should govern (a) personnel responsibility in using the health service and reporting illness; (b) work restrictions; and (c) clearance to resume work after an illness that required work restriction. The policies also should identify persons who have the authority to remove personnel from duty (IB). Obtain appropriate cultures from, and exclude from duty, surgical personnel who have draining skin lesions until infection has been ruled out or personnel have received adequate therapy and infection has resolved (IB). Do not routinely exclude surgical personnel who are colonized with organisms such as S. aureus (nose, hands, or other body site) or group A. Streptococcus, unless such personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting (IB).
Antimicrobial prophylaxis. Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI for a specific operation and published recommendations (IA). Administer by the intravenous route the initial dose of prophylactic antimicrobial agent, timed such that a bactericidal concentration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room (IA). Before elective colorectal operations in addition to the above, mechanically prepare the colon by use of enemas and cathartic agents. Administer nonabsorbable oral antimicrobial agents in divided doses on the day before the operation (IA). For high-risk cesarean section, administer the prophylactic antimicrobial agent immediately after the umbilical cord is clamped (IA). Do not routinely use vancomycin for antimicrobial prophylaxis (IB).
Ventilation. Maintain positive-pressure ventilation in the operating room with respect to the corridors and adjacent areas (IB). Maintain a minimum of 15 air exchanges per hour, of which at least three should be fresh air (IB). Filter all air, recirculated and fresh, through the appropriate filters per the American Institute of Architects' recommendations (IB). Introduce all air at the ceiling, and exhaust near the floor (IB). Do not use UV radiation in the operating room to prevent SSI (IB). Keep operating room doors closed except as needed for passage of equipment, personnel, and the patient (IB).
Cleaning and disinfection of environmental surfaces. When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an operation, use an EPA-approved hospital disinfectant to clean the affected areas before the next operation (IB). Do not perform special cleaning or closing of operating rooms after contaminated or dirty operations, and do not use tacky mats at the entrance to the operating room suite or individual operating rooms for infection control (IB).
Microbiologic sampling. Do not perform routine environmental sampling of the operating room. Perform microbiologic sampling of operating room environmental surfaces or air only as part of an epidemiologic investigation (IB).
Sterilization of surgical instruments. Sterilize all surgical instruments according to published guidelines. Perform flash sterilization only for patient care items that will be used immediately (e.g., to reprocess an inadvertently dropped instrument). Do not use flash sterilization for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time (IB).
Surgical attire and drapes. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation, and wear a cap or hood to fully cover hair on the head and face when entering the operating room (IB). Do not wear shoe covers for the prevention of SSI (IB). Wear sterile gloves if a scrubbed surgical team member, and put on gloves after donning a sterile gown (IB). Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration) (IB). Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials (IB).
Asepsis and surgical technique. Adhere to principles of asepsis when placing intravascular devices (e.g. central venous catheters), spinal, or epidural anesthesia catheters or when dispensing and administering intravenous drugs (IA). Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies (i.e., sutures, charred tissues, necrotic debris), and eradicate dead space at the surgical site (IB). Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be contaminated heavily (e.g., Class III and Class IV) (IB). If drainage is necessary, use a closed suction drain. Place a drain through a separate incision distant from the operative incision. Remove the drain as soon as possible (IB).
Postoperative incision care. Protect with a sterile dressing for 24 to 48 hours postoperatively an incision that has been closed primarily (IB). Wash hands before and after dressing changes and any contact with the surgical site (IB).
Most of these guidelines are general infection control practices that should already be a part of our standard practice in surgery. The guidelines that are listed have documented studies that support each of them. Make routine rounds in surgery to observe the staff. If any of your surgical procedures infection rates fall outside of the acceptable limits, carefully review the guidelines and compare them to your practice to identify an opportunity for improvement. P
Vickie VanDeventer RN, BSN, CIC, is an Infection Control Practitioner at Bloomington Hospital & Healthcare System in (Bloomington, Ind). Bloomington Hospital is a 297-bed acute care facility. She is an active member in APIC and currently serves as program chair for APIC Indiana.
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Superficial Incisional SSI
Infection occurs within 30 days after the operation and infection involves only skin or subcutaneous tissue of the incision and at least one of the following:
1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.
3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is opened deliberately by surgeon, unless incision is culture-negative.
4. Diagnosis of superficial incision SSI by the surgeon or attending physician.
Deep Incisional SSI
Infection occurs within 30 days after the operation if no implant is left in place or within one year if implant is in place, the infection appears to be related to the operation, and infection involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following:
1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site.
2. A deep incision spontaneously dehisces or is opened deliberately by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38ºC), localized pain, or tenderness, unless site is culture-negative.
3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination.
4. Diagnosis of a deep incisional SSI by a surgeon or attending physician.
Infection occurs within 30 days after the operation if no implant is left in place or within one year if implant is in place, the infection appears to be related to the operation, and infection involves any part of the anatomy (e.g., organs or spaces) other than the incision, which was opened or manipulated during an operation and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab wound into the organ/space.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination.
4. Diagnosis of an organ/space SSI by a surgeon or attending physician.
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