SSI Prevention Pointers from Industry

ICT asked members of industry for their insights on surgical site infection (SSI) prevention.

Surgical site infections (SSIs) can result from a variety of different scenarios such as the patients contaminated skin, poor sterilization and disinfection practices, or also failure to maintain a clean environment in the operating suite. The most fundamental infection prevention and control intervention is always hand hygiene. Hand hygiene has consistently proven to break the chain of infection transmission. Additionally, however, recent studies have documented the role of the environment in the transmission of infections. Maintaining a clean and sanitary environment will prevent many contaminants from entering the surgical field and most importantly the patient. Given the nature of surgery, the surgical theater is a particularly high-risk setting. In many cases the patients skin is not intact, and therefore unable to function as a protective mechanism from external contamination from the air, environmental surfaces, contaminated hands and equipment. Given the critical role of the environment, thorough disinfection of the environment is a fundamental principle for prevention of SSIs. The use of an EPA-registered disinfectant product, such as germicidal wipes,  should be focused on high-touch surfaces that may touch multiple patients and healthcare workers such as overhead lights, the OR table, anesthesia equipment, mayo stands, etc. Disinfectant products that produce aerosols should not be used due to safety.
-- J. Hudson Garrett Jr., PhD, MSN, MPH, FNP-BC, VA-BC, senior director of clinical affairs, PDI

Reference: Recommended Practices for Environmental Cleaning in the Perioperative Setting, Association for periOperative Registered Nurses (AORN), 2011.

Nasal carriage of S. aureus has been identified as a major risk factor for wound infections after both joint arthroplasty and cardiac surgery.^1-2  Approximately 30 percent of the population carries S. aureus in their nose and 1 percent carry MRSA.³ A number of strategies employ the use of topical antimicrobial agents to reduce the bacterial load on the patients skin prior to surgery. An emerging practice is topical therapy to reduce bacteria in the nares prior to surgery.  This has primarily been done with a topical antibiotic, and requires a patient visit prior to the procedure, filling of a prescription, and compliance with application of the agent. With socioeconomic complexities that include lack of health insurance or prescription drug coverage, age-old medication non-compliance, and emerging antimicrobial resistance, it is worthwhile to consider additional options for intervention.
Another practice is the use of a 5 percent povidone iodine antiseptic which is formulated to work in the unique physiology of the nares.  Because its an antiseptic, there is no resistance.  It is an easy clinician applied pre-surgical application (one hour prior to surgery) within the hospital to ensure adherence to protocol.⁴  Simple, directly administered strategies at the point of care such as this may prove successful given the complexities of patient compliance with self administered protocols.
-- Michelle Hulse Stevens, MD, medical director, 3M Infection Prevention Division

References:
1. Kalmeijer MD, van Nieuwland-Bollen E, Bogaers-Hofman D, de Baere GAJ, Kluytmans JAJW. Nasal Carriage of Staphlococcus aureus as a Major Risk Factor for Surgical Site Infections in Orthopedic Surgery. Infection Control and Hospital Epidemiology: 2000;21: 319-323.
2. Kluytmans JAJW, Mouton JW, Ijzerman EPF, et al. Nasal carriage of Staphlococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 1995;171:216-219.
3. Kuehnert MJ, et al. Prevalence of Staphylococcus aureus nasal colonization in the United States, 20012002. Journal of Infectious Diseases 2006;193:172-179. National Center for Infectious Diseases and National Center for Health Statistics, Centers for Disease Control and Prevention.
4. Hogenmiller JR, Hamilton J,  Clayman T,et al. Preventing Orthopedic Total Joint Replacement Surgical Site Infections through a Comprehensive Best Practice Bundle/Checklist. Presented at APIC Conference, Baltimore, June 2011.

Most surgical teams are well aware of the SSI prevention bundled components and practice them. Yet, we still have life-altering infections.  I would like to speak to a known contributor to infections that is far too rarely addressed.  Most of us know that lint is a potential fomite. As the Association for periOperative Registered Nurses (AORN) explains, lint can pick up bacteria in the environment and transport them into the open wound. However, even sterile lint fibers in a wound can significantly increase the risk of infection by lowering the infectious dose. In other words, it can take far less bacteria to initiate an infection if these foreign bodies are present. When lint and bacteria are present at the same time, the white cells attack what they perceive as the larger threat the lint -- and ignore the few bacteria contaminating the site. The bacteria can then multiply rapidly while being ignored by the distracted immune response team. Elek demonstrated that the presence of sterile particles in a wound reduced the number of bacteria required to cause an infection from 10,000,000 when no particles were present to only 100 bacteria when sterile particles were introduced. Jaffray demonstrated that sterile particles increased the number of wounds infected by 1,000 bacteria from 1/10 wounds with no particles, to 9/10 when sterile particles were present. Drapes containing cellulose (paper or cotton ) in the body or fenestration area of the drape produce particularly bioactive, immune-distracting lint. Ensuring that gowns, drapes, sterilization wrap and other barrier fabrics are low-linting and that they resist lint producing abrasion is an important component in the war against surgical site infections.  
-- Wava Truscott, PhD, MBA, director of scientific affairs and clinical education, Kimberly-Clark Health Care

With increasing evidence that the environment plays a role in the transmission of pathogens to patients, environmental hygiene is gaining attention as a focus for all areas of the hospital. Within the OR an emphasis on using standardized cleaning methods to reduce infections in the surgical suite by objectively measuring cleaning outcomes is emerging. Many multi-drug resistant organisms such as MRSA, VRE and C. difficile can persist in the environment for extended periods of time. Several studies have shown that improved environmental cleaning decreases patient acquisition of these pathogens. Additionally single-use products including table linens, microfiber mops and microfiber cloths further help to eliminate cross contamination. It is important to have a comprehensive environmental hygiene program for the OR that promotes standardized and consistent cleaning procedures. This is possible by providing effective cleaning tools, objective tracking of cleaning outcomes, and ongoing training and education. These components are critical to achieving superior cleaning outcomes in the OR and helping to reduce the potential for surgical site infections. Reducing the potential for surgical site infections starts with a clean OR environment. A programmatic approach to environmental hygiene can help improve end of case and terminal cleaning in the OR. 
-- Boyd Wolf, program leader, Healthcare Research, Development and Engineering, Ecolab

Normothermias relationship to surgical site infections has garnered special attention with numerous evidence-based initiatives, like SCIP-Inf-10, citing normothermia maintenance as a tool in surgical site infection (SSI) reduction efforts. Maintaining normothermia is one of the easiest, least expensive and most effective benefits to offer patients. Forced-air warming is the gold standard of care for managing perioperative normothermia throughout the world.^1-4 Its an effective tool in complying with healthcare initiatives and improving patient outcomes. Forced-air warming is effective due to the properties of convection and radiation; heat transfer improves due to the movement of air across the surface of the patients skin. This allows forced-air blankets to transfer enough heat while operating at a relatively low temperature. Forced-air warmings 25-year track record of safety and efficacy is supported by its use with more than 160 million patients and more than 100 published papers documenting its clinical benefits. Its the only warming modality with published clinical outcome data supporting effectiveness in reducing SSIs, and studies have found forced-air warming to be the most effective method in general for preventing and treating unintended hypothermia.⁵-- Greta Deutsch is the public relations and communications specialist at Arizant.

References:
1. Hynson JM, Sessler DI. Intraoperative warming therapies: a comparison of three devices. J Clin Anesth 1992; 4:194-9.
2. Kurz  A, Kurz M, Poeschl G, Faryniak B, Redl G, Hackl W. Forced-air warming maintains intraoperative normothermia better than circulating water mattress. Anesth Analg 1993;77:89-95.
3.  Borms SF, Englelen SL, Himpe DG, Suy MR, Theunissen WJ. Bair Hugger forced-air warming maintains normothermia more effectively than thermo-lite insulation. J Clin Anesth 1994;6:3037.
4. Brauer A, Pacholik L, Perl T, English MJ, Weyland W, Braun U. Conductive heat exchange with a gel-coated circulating water mattress. Anesth Analg 2004;99:17426.
5. Hooper V, et al. American Society of PeriAnesthesia Nurses Development Panel. Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia. Journal of PeriAnesthesia Nursing. 2009; 24(5): 271-287.

Every day we make choices to protect ourselves from risks. We schedule checkups, routinely maintain our cars and pay for insurance. Why do we do this? Ultimately we know it is smarter to pay the minimal costs to prepare for problems, rather than pay the high costs to manage these problems when they occur. Following this same practice, using antimicrobial dressings as a preventative measure may help to minimize risk and control the costs of surgical site infections (SSI). The average incremental cost of an SSI is estimated to be $25,546.¹ Cost factors include the expense of treating an infected wound, increased hospital stay time and readmission. There are a variety of affordable antimicrobial dressings on the market that reduce the risk of SSIs and are backed by evidence-based practice. Some applicable studies have shown an 81percent reduction in SSIs² with the use of these products. Some antimicrobial dressings require no change in protocol or activation, and can help protect patients from SSIs for pennies a day. With enforcement of mandatory reporting in 2012, no reimbursement for SSIs, and tighter hospital budgets, now is the time to use antimicrobial dressings prophylactically to protect your facility and your patients from SSIs.
-- David Clare, director of marketing, wound, Covidien

References:
1. Stone, PW, Larsen E, Kawar LN. A systematic audit of economic evidence linking nosocomial  infections and infection control interventions: 1990-2000. Am J Infect Control. 2002:30: 145-152
2. Lovelace, L. Just When You Thought Your Statistics Were Good Enough. APIC News. Winter 2007-2008:25-30.

Antimicrobial prophylaxis  (AMP) is recognized globally as an important step in reducing surgical site infections (SSIs).^1-2 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.^1,3 AMP should be administered within one hour before surgical incision, using an appropriate dosage for individual body mass, to allow optimal therapeutic levels. Serum levels should be maintained throughout surgery, with special attention to the antimicrobial half-life and duration of surgery.  AMP should be discontinued within 24 hours after the end of surgery to reduce the risk of developing resistance.^1-2  Because the timing of AMP administration and discontinuation are so important to its effectiveness, guidelines from Australia encourage the use of protocols, computerized orders, and checklists to promote adherence.²Â  In addition, surgical and infection prevention organizations promote the effectiveness of AMP and emphasize its importance in reducing SSIs. Nevertheless, a national survey conducted in the United States found that only 55.7 percent of surgical patients received an antimicrobial within an hour before incision, and only 40.7 percent had antimicrobial therapy discontinued within 24 hours of surgery.4 Better adherence to AMP guidelines can further reduce the incidence of SSIs.
-- Cindi Crosby, PhD, vice president, global medical affairs, CareFusion

1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:247-78. PMID:10219875
2. Safer Systems Saving Lives. Preventing Surgical Site Infection Version 4. Toolkit.  Victorian Government Department of Human Services, Melbourne, Victoria. 2005. Available at:  http://www.health.vic.gov.au/sssl/downloads/prev_surgical.pdf.  Accessed on January 23, 2012.
3. Florman S, Nichols RL. Current approaches for the prevention of surgical site infections. Am J Infect Dis 2007;3:51-61.
4. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg. 2005;140(2):174-82. PMID:15724000.

A study by McGovern (2011) in the Journal of Bone and Joint Surgery revealed a practice that significantly reduces infections in orthopedic surgery. By switching from forced-air warming to air-free warming, the authors showed a 74 percent decrease in deep joint infections: from 3.1 percent to 0.8 percent. According to the researchers, Excess heat from forced-air warming escaped near the floor and generated convection currentstransporting contaminated floor-level air upwards and into the surgical site. Conductive fabric warming had no such effect.  The assumption that forced-air warming decreases SSIs is simply not valid for implant surgery, at least as compared to warming modalities that do not generate significant levels of waste heat. Although Kurz (1996) shown that forced-air warming reduces SSI rates during colon-surgery, theres a fundamental difference in the causative mechanisms of soft-tissue infections versus deep-joint infections.  Soft-tissue infections require inoculums of 1,000,000 germs and typically come from adjacent skin or cut bowel (Elek and Cohen, 1957). In contrast, it takes only one bacterium to infect a new prosthetic joint and that bacterium typically comes from airborne transmission (Lidwell, 1983).  As McGovern concluded, Air-free warming is, therefore, recommended over forced-air warming for orthopedic procedures.
-- Scott D. Augustine, MD, president, Augustine Temperature Management

References:
1. Elek SD and Cohen PE. The virulence of Staphylococcus pyogenes for man. A study of the problem of wound infection. British J Experimental Path. 1957;38, 573-586.
2. Kurz A, et al. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten
hospitalization. NEJM. 1996;334:1209-1215.
3. Lidwell OM, et al, Bacteria isolated from deep joint sepsis after operation for a total hip or knee replacement and the sources of the infection with Staphylococcus aureaus. J  Hosp Infect. 4(1983) 19-29.
4. McGovern PD, Reed MR et al, Forced Air Warming and Ultra-Clean Ventilation Do Not Mix: An Investigation of Theatre Ventilation, Patient Warming and Joint Replacement Infection in Orthopaedics. J. Bone and Joint Surgery Br, 2011;93(11), 1537-44.

* Disclosure for McGovern study: Mark Albrecht, who contributed to the statistical analysis, has been an employee of Augustine Biomedical + Design.  He currently is on a fellowship from the company, pursuing a masters in statistics at the University of Minnesota. This relationship was revealed in the study by the following: The author or one or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article.