SSI Prevention: Updated Research Findings, Guidelines & Recommendations Offer Improved Knowledge

By Kelly M. Pyrek

Updated guidelines and recommendations from across the medical community are giving surgical services clinicians better knowledge and tools with which to protect patients and achieve improved outcomes. Let's examine the most recent developments in surgical site infection (SSI) prevention.
While hospitals grapple with what operating room (OR) infection control procedures work best, a recent study of Texas hospitals has determined two areas that stand out: mandating sterile operating conditions at or close to the wound itself; and tracking in-hospital outcomes on SSIs and sharing that information with surgeons and other OR staff.

"In contrast, our research team found that policies regulating the attire of OR personnel had no measurable impact on infection rates," says lead author Thomas A. Aloia, MD, FACS, department of surgical oncology, the University of Texas MD Anderson Cancer Center, Houston. Aloia presented the findings at the 2017 American College of Surgeons Quality and Safety Conference in New York in July. The results have been published in the Journal of the American College of Surgeons.

"Every institution wants to lower complication rates and, in particular, wound infection rates," Aloia says. "However, we have limited resources to carry out quality assessment and quality improvement. What's important about this study is that it brings feasibility to hospitals that may be considering 80 possible variables to intervene on. To get off to a strong start, they can begin by looking at conditions right at the wound and their reporting practices. A focus on these elements should produce the biggest impact for quality improvement initiatives."
He adds, "our findings can really help individual hospitals that are working on OR attire policy and other standard operating procedures and regulations to appropriately scale what they are going to emphasize."

For this study, Aloia and his colleagues surveyed surgeon leaders at 20 Texas hospitals affiliated with the Texas Alliance for Surgical Quality (TASQ), a collaborative of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®). The survey asked respondents to rank how well the three key disciplines on the surgical team--surgery, anesthesia, and nursing--adhere to 38 separate infection control practices in six different categories: attire; preoperative preparation; during-surgery protocols; antibiotics; postoperative care; and outcomes reporting. The study used a four-point scale to rank the level of adherence. The researchers also collected outcomes data on risk-adjusted odds ratios of surgical site infections contained in the July 2016 ACS NSQIP hospital-level risk-adjusted reports. They then compared compliance rates between the best and worst performers.

Almost all hospitals reported maximal adherence to surgical care improvement project metrics, including removal of patient hair around the wound site with clippers and proper use and dosing of preventive antibiotics. The subset of hospitals that were most compliant with eight other practices demonstrated the lowest surgical site infection rates. These practices included the patient showering before an operation; best practice preparation of the skin in the OR; and use of clean instruments, gowns, and gloves for closing wounds and changing dressings, Aloia says.

"The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appropriately--all those things that happened right at the level of the wound," Aloia says. "In addition, the hospitals that reported out their data on a formal basis--monthly or quarterly--to their surgeons, departments, and institutions also had the highest performance."

"These findings are supported by three recently published studies, including surgical site infection guidelines from the Centers for Disease Control (2017) and the American College of Surgeons and Surgical Infection Society (2016)," the authors note.

By the same token, Aloia and his colleagues found that OR attire practices, particularly those that apply to OR personnel away from the immediate field of surgery, had no impact on SSI rates. These practices included implementation of specific rules for surgical caps, undershirts, and shoes and shoe coverings; restrictions on jewelry and nail polish; coverage requirements for forearms and head and facial hair; and even presence of personal bags in the OR.

Those types of regulations provided the impetus for the study, Aloia explains. "Although we would never advocate sacrificing safety, such regulations don't seem to have data to back them up," he said.

The next step, Aloia said, is to feed back the data to the participating programs and to revisit in a year how the lower performing programs have changed their infection control practices to be more vigilant about effective practices at and near the surgical field and report outcomes and if the SSI rates improve as a result. "If that happens and their performance improves, that improvement would validate the effects we saw in our study," he says.

CDC/HICPAC Update to SSI Prevention Guideline

In May 2017, the Centers for Disease Control and Prevention (CDC)'s Healthcare Infection Control Practices Advisory Committee (HICPAC) published its Guideline for the Prevention of Surgical Site Infection, 2017, in the journal JAMA Surgery. This targeted systematic review of the literature synthesizes evidence-based recommendations for the prevention of SSIs.

The authors summarize, "Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI."

In the guideline, Berríos-Torres, et al. (2017) focus on select areas for the prevention of SSI deemed important to undergo evidence assessment for the advancement of the field. They are as follows:

Parenteral Antimicrobial Prophylaxis
- Administer preoperative antimicrobial agents only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. (Category IB) No further refinement of timing can be made for preoperative antimicrobial agents based on clinical outcomes. (No recommendation/unresolved issue.)
- Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures. (Category IA)
Note: The literature search did not identify randomized controlled trials that evaluated the benefits and harms of weight-adjusted parenteral antimicrobial prophylaxis dosing and its effect on the risk of SSI. Also, the search did not identify sufficient randomized controlled trial evidence to evaluate the benefits and harms of intraoperative redosing of parenteral prophylactic antimicrobial agents for the prevention of SSI. Both are unresolved issues.
- In clean and clean-contaminated procedures, do not administer additional prophylactic antimicrobial agent doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA)

Nonparenteral Antimicrobial Prophylaxis
- Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding intraoperative antimicrobial irrigation for the prevention of SSI. (No recommendation/unresolved issue.)
- The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antimicrobial solutions before implantation for the prevention of SSI. (No recommendation/unresolved issue.)
- Do not apply antimicrobial agents (ointments, solutions, or powders) to the surgical incision for the prevention of SSI. (Category IB)
- Consider the use of triclosan-coated sutures for the prevention of SSI. (Category II)
- Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding antimicrobial dressings applied to surgical incisions after primary closure in the operating room for the prevention of SSI. (No recommendation/unresolved issue.)
Glycemic Control
- Implement perioperative glycemic control and use blood glucose target levels less than 200 mg/dL in patients with and without diabetes. (Category IA)
- The search did not identify randomized controlled trials that evaluated lower (<200 mg/dL) or narrower blood glucose target levels than recommended in this guideline nor the optimal timing, duration, or delivery method of perioperative glycemic control for the prevention of SSI. (No recommendation/unresolved issue.)

Normothermia
- Maintain perioperative normothermia. (Category IA)
- The search did not identify randomized controlled trials that evaluated strategies to achieve and maintain normothermia, the lower limit of normothermia, or the optimal timing and duration of normothermia for the prevention of SSI. (No recommendation/unresolved issue.)

Antiseptic Prophylaxis
- Advise patients to shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. (Category IB)
- Randomized controlled trial evidence suggested uncertain trade-offs between the benefits and harms regarding the optimal timing of the preoperative shower or bath, the total number of soap or antiseptic agent applications, or the use of chlorhexidine gluconate washcloths for the prevention of SSI. (No recommendation/unresolved issue.)
- Perform intraoperative skin preparation with an alcohol-based antiseptic agent unless contraindicated. (Category IA)
- Application of a microbial sealant immediately after intraoperative skin preparation is not necessary for the prevention of SSI. (Category II)
- The use of plastic adhesive drapes with or without antimicrobial properties is not necessary for the prevention of SSI. (Category II)
- Consider intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI. Intraperitoneal lavage with aqueous iodophor solution in contaminated or dirty abdominal procedures is not necessary. (Category II)
- The search did not identify randomized controlled trials that evaluated soaking prosthetic devices in antiseptic solutions before implantation for the prevention of SSI. (No recommendation/unresolved issue.)
- Randomized controlled trial evidence was insufficient to evaluate the trade-offs between the benefits and harms of repeat application of antiseptic agents to the patient’s skin immediately before closing the surgical incision for the prevention of SSI. (No recommendation/unresolved issue.)

Orthopedic Surgical Space Suit
- Available evidence suggested uncertain trade-offs between the benefits and harms of orthopedic space suits or the healthcare personnel who should wear them for the prevention of SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)
Postoperative Antimicrobial Prophylaxis Duration With Drain Use
- In prosthetic joint arthroplasty, in clean and clean-contaminated procedures, do not administer additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the presence of a drain. (Category IA)
Biofilm
- Available evidence suggested uncertain trade-offs between the benefits and harms regarding cement modifications and the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)
- The search did not identify studies evaluating prosthesis modifications for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)
- The search did not identify studies evaluating vaccines for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)
- The search did not identify studies evaluating biofilm control agents, such as biofilm dispersants, quorum sensing inhibitors, or novel antimicrobial agents, for the prevention of biofilm formation or SSI in prosthetic joint arthroplasty. (No recommendation/unresolved issue.)

As the guideline authors explain, "The number of unresolved issues in this guideline reveals substantial gaps that warrant future research. A select list of these unresolved issues may be prioritized to formulate a research agenda to advance the field. Adequately powered, well-designed studies that assess the effect of specific interventions on the incidence of SSI are needed to address these evidence gaps. Subsequent revisions to this guideline will be guided by new research and technological advancements for preventing SSIs."

AHRQ Toolkit

The Agency for Healthcare Research and Quality (AHRQ) has introduced its Toolkit to Promote Safe Surgery, designed to help perioperative and surgical units in hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent SSIs. The toolkit has evidence-based, practical resources that reflect the real-world experiences of the frontline clinicians and subject matter experts who participated in the AHRQ Safety Program for Surgery, a national implementation project in which approximately 200 hospitals participated and successfully reduced surgical site infections. It builds on AHRQ’s Comprehensive Unit-based Safety Program (CUSP) and the core CUSP toolkit by providing specific tools focused on the surgical setting to help hospitals reduce surgical site infections and other complications.

The toolkit has two complementary guides that should be used together and are a good starting point: Applying CUSP To Promote Safe Surgery, and Surgical Complication Prevention. These two guides address respectively adaptive and technical work, which are both critical elements for improvement to occur. Technical work changes procedural aspects of care that can be explicitly defined, such as surgical skin preparation procedures. Adaptive work is designed to change the attitudes, values, beliefs, and behaviors of the people who deliver care and improve safety culture within an organization, thereby enabling consistent use of evidence-based practices. Both guides should be used simultaneously. Supplemental tools accompany the guides.

The toolkit also includes 15 instructional modules to help clinical teams address specific areas of competency. The modules are spread across the three phases that clinical teams will undergo as part of their quality improvement efforts: onboarding, implementation, and sustainability. The AHRQ toolkit is available at: https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/surgery/index.html

AORN Guidelines

The Association of periOperative Registered Nurses (AORN) has published the 2018 Guidelines for Perioperative Practice with five updated guidelines, as well as a completely new guideline that addresses team communication. Guidelines for Perioperative Practice, published each January, is a collection of 32 guidelines that provide evidence-based recommendations to deliver safe perioperative patient care and achieve workplace safety.

The Guideline for Team Communication is the first evidence-based guideline for effective communication in the perioperative environment. This new guideline expands upon and supersedes the Guideline on Transfer of Patient Care Information.

“Every AORN guideline recommends team involvement and shared communication with all stakeholders on the perioperative team, yet research still identifies ineffective team communication as a common cause of adverse events,” says Ramona Conner, MSN, RN, CNOR, editor-in-chief of AORN’s Guidelines for Perioperative Practice. “Understanding the evidence supporting strategies to strengthen team communication is critical for teams to successfully implement all AORN guidelines for safe perioperative care.”

The new Guideline for Team Communication provides guidance for improving perioperative team communication through a culture of safety. Recommendations cover key opportunities for communication throughout a patient’s continuum of surgical care, such as briefings, surgical pauses, and hand-overs. Evidence-based guidance also addresses opportunities to strengthen team communication, such as through simulation training.
The updated Guideline for Positioning the Patient offers more detailed guidance for evidence-based practices that address key steps in safe patient positioning, including preoperative and postoperative positioning assessment and selection of support surfaces and positioning equipment and devices based on patient- and procedure-specific factors. One new recommendation addresses neurophysiological monitoring used intraoperatively for early detection of potential positioning injuries.

The updated Guideline for Medication Safety reflects new evidence-based practice insights from case studies and other research on preventing medication errors, including safe injection practices and correct management of compounded drugs. It also covers new recommendations for safely handling hazardous medications such as antineoplastic drugs.

The updated and retitled Guideline for the Prevention of Venous Thromboembolism provides broader guidance that addresses protocols for prevention of venous thromboembolism (VTE), including prevention of deep vein thrombosis (DVT) by mechanical and pharmacologic prophylaxis and prevention of pulmonary embolism (PE) as a complication of DVT. The updated guideline explores in much more depth the range of patient- and procedure-specific risk factors for VTE that should be assessed for preoperatively.

The updated and retitled Guideline for Medical Device and Product Evaluation provides more detailed evidence-based guidance to perioperative team members for implementing a standardized evaluation approach to selecting medical devices and products for use in the perioperative setting. Citing new evidence that supports the important role of the RN in the evaluation process, the guideline also outlines a recommended approach for conducting a value analysis as part of the evaluation process to ensure selected products fit within the health care organization’s fiscal strategy.

The updated and retitled Guideline for Manual Chemical High-Level Disinfection changes focus to address safe manual chemical high-level disinfection of reusable semi-critical items, while also discussing the evidence-based rationale for using automated HLD as a superior method to protect patients and personnel. A new recommendation for high-level disinfection or sterilization of endocavity ultrasound probes highlights the risk for probe contamination with lower levels of disinfection, even when a sheath or cover is used. The recommendation also notes that some HLDs are not effective against all pathogens that could be on the probes, such as human papilloma virus (HPV).

“Our world is moving rapidly and it is very challenging for the perioperative professional to keep up with all of the new evidence coming out to ensure safe perioperative practice,” Conner says. “AORN is dedicated to making sense of this wealth of evidence by exploring the literature, rating the evidence, and shaping practice recommendations that perioperative practitioners can easily apply in their unique practice settings.”

WHO Recommendations

In late 2016, the World Health Organization (WHO) provided guidelines offering 29 ways to stop surgical infections and avoid superbugs. Patients preparing for surgery should always have a bath or shower but not be shaved, and antibiotics should only be used to prevent infections before and during surgery, not afterwards, according to the WHO guidelines.

The "Global Guidelines for the Prevention of Surgical Site Infection" includes a list of concrete recommendations distilled by 20 of the world’s leading experts from 26 reviews of the latest evidence. The recommendations, published in The Lancet Infectious Diseases, are designed to address the increasing burden of healthcare-associated infections on both patients and healthcare systems globally.

"No one should get sick while seeking or receiving care," says Dr. Marie-Paule Kieny, WHO’s assistant director-general for health systems and innovation. "Preventing surgical infections has never been more important but it is complex and requires a range of preventive measures. These guidelines are an invaluable tool for protecting patients."

In the United States, SSIs contribute to patients spending more than 400,000 extra days in hospital at a cost of an additional $900 million per year, according to WHO.

The guidelines include 13 recommendations for the period before surgery, and 16 for preventing infections during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery and the best way for surgical teams to clean their hands, to guidance on when to use antibiotics to prevent infections, what disinfectants to use before incision, and which sutures to use.

"Sooner or later many of us will need surgery, but none of us wants to pick up an infection on the operating table," says Dr. Ed Kelley, director of WHO’s Department of Service Delivery and Safety. "By applying these new guidelines surgical teams can reduce harm, improve quality of life, and do their bit to stop the spread of antibiotic resistance. We also recommend that patients preparing for surgery ask their surgeon whether they are following WHO’s advice."

No international evidence-based guidelines had previously been available and there are inconsistencies in the interpretation of evidence and recommendations in existing national guidelines. The new WHO guidelines are valid for any country and suitable to local adaptations, and take account of the strength of available scientific evidence, the cost and resource implications, and patient values and preferences. They complement WHO’s Surgical Safety Checklist, which gives a broad range of safety measures, by giving more detailed recommendations on preventing infections.

The WHO guidelines recommend that antibiotics be used to prevent infections before and during surgery only, a crucial measure in stopping the spread of antibiotic resistance. Antibiotics should not be used after surgery, as is often done. As we know, antibiotic resistance occurs when bacteria change in response to the use of these medicines. Resistance develops naturally over time, but misuse of antibiotics in humans and animals is rapidly accelerating the process. Antibiotic resistance is putting the achievements of modern medicine at risk. Without effective antibiotics for the prevention and treatment of infections, organ transplants, cancer chemotherapy and surgeries such as caesarean sections and hip replacements become much more dangerous. This leads to longer hospital stays, higher medical costs, and increased mortality.

Here's a summary of key WHO recommendations:
1. Preoperative bathing
WHO (2016) states, "It is good clinical practice for patients to bathe or shower prior to surgery. The panel suggests that either plain soap or an antimicrobial soap may be used for this purpose. The panel decided not to formulate a recommendation on the use of CHG-impregnated cloths for the purpose of reducing SSI due to the very low quality of evidence."
2. Decolonization with mupirocin ointment with or without CHG body wash for the prevention of Staphylococcus aureus infection in nasal carriers
WHO (2016) states: "The panel recommends that patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of S. aureus should receive perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash. The panel suggests considering to treat also patients with known nasal carriage of S. aureus undergoing other types of surgery with perioperative intranasal applications of mupirocin 2% ointment with or without a combination of CHG body wash."
3. Screening of ESBL colonization and the impact on antibiotic prophylaxis
WHO (2016) states: "The panel decided not to formulate a recommendation due to the lack of evidence."
4. Optimal timing for preoperative SAP
WHO (2016) states: "The panel recommends that SAP should be administered prior to the surgical incision when indicated (depending on the type of operation). The panel recommends the administration of SAP within 120 minutes before incision, while considering the half-life of the antibiotic."
5. Hair removal
WHO (2016) states: "The panel recommends that in patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the OR."
6. Surgical site preparation
WHO (2016) states: "The panel recommends alcohol-based antiseptic solutions based on CHG for surgical site skin preparation in patients undergoing surgical procedures."
7. Surgical hand preparation
WHO (2016) states: "The panel recommends that surgical hand preparation should be performed by scrubbing with either a suitable antimicrobial soap and water or using a suitable alcohol-based handrub before donning sterile gloves."
8. Maintaining normal body temperature (normothermia)
WHO (2016) states: "The panel suggests the use of warming devices in the OR and during the surgical procedure for patient body warming with the purpose of reducing SSI."
9. Drapes and gowns
WHO (2016) states: "The panel suggests that either sterile, disposable non-woven or sterile, reusable woven drapes and gowns can be used during surgical operations for the purpose of preventing SSI. The panel suggests not to use plastic adhesive incise drapes with or without antimicrobial properties for the purpose of preventing SSI."
10. Wound protector devices
WHO (2016) states: "The panel suggests considering the use of wound protector devices in clean-contaminated, contaminated and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI".
11. Incisional wound irrigation
WHO (2016) states: "The panel considered that there is insufficient evidence to recommend for or against saline irrigation of incisional wounds before closure for the purpose of preventing SSI. The panel suggests considering the use of irrigation of the incisional wound with an aqueous PVP-I solution before closure for the purpose of preventing SSI, particularly in clean and clean-contaminated wounds. The panel suggests that antibiotic incisional wound irrigation should not be used for the purpose of preventing SSI."
12. Prophylactic negative pressure wound therapy
WHO (2016) states: "The panel suggests the use of prophylactic negative pressure wound therapy in adult patients on primarily closed surgical incisions in high-risk wounds for the purpose of the prevention of SSI, while taking resources into account."
13. Use of surgical gloves
WHO (2016) states: "The panel decided not to formulate a recommendation due to the lack of evidence to assess whether double-gloving or a change of gloves during the operation or the use of specific types of gloves are more effective in reducing the risk of SSI."
14. Antimicrobial-coated sutures
WHO (2016) states: "The panel suggests the use of triclosan-coated sutures for the purpose of reducing the risk of SSI, independent of the type of surgery."
15. Laminar flow ventilation systems in the context of OR ventilation
WHO (2016) states: "The panel suggests that laminar airflow ventilation systems should not be used to reduce the risk of SSI for patients undergoing total arthroplasty surgery."
16. Advanced dressings
WHO (2016) states: "The panel suggests not using any type of advanced dressing over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI."

References:

AHRQ. Surgical Complication Prevention Guide. December 2017.

AORN. Guidelines for Perioperative Practice. 2018.

Berríos-Torres SI, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. Published online May 3, 2017. doi:10.1001/jamasurg.2017.0904

Davis CH, Kao LS, Fleming JB, Aloia TA. Multi-Institution Analysis of Infection Control Practices Identifies the Subset Associated with Best Surgical Site Infection Performance: A Texas Alliance for Surgical Quality Collaborative Project. Journal of the American College of Surgeons. Aug. 16, 2017.

World Health Organization. Global Guidelines for the Prevention of Surgical Site Infection. 2016.