Proactive Prevention Needed To Stop Surgical Site Infections

By Sarah Pressman Lovinger

CHICAGO -- Fully half of the surgical site infections that occur could be avoided if surgeons applied known methods of prevention, said Dr. Donald Fry at the annual clinical congress of the American College of Surgeons.

"The evidence is there, and the practice of surgery does not pay attention to it," said Dr. Fry, professor emeritus at the University of New Mexico, Albuquerque.

In addressing this "huge problem," Dr. Fry cited surveillance data from the Centers for Disease Control and Prevention, which show that 2.6% of the 30 million people who have surgery each year develop surgical site infections (SSIs). Dr. Fry believes these data underestimate the actual number of such infections.

While SSIs rarely lead to excess deaths, they increase the average length of stay in the hospital, which drives up overall costs. "There is no question that surgeons will be increasingly responsible for SSIs" as a way to reduce costs, Dr. Fry said.

To lower SSI risk, surgeons should reduce the inoculum through good skin preparation and surgical technique that minimizes sutures and other foreign bodies. Careful use of electrocautery can also lower the risk of an SSI. "Please don't use the electrocautery like a flame thrower and expect that you are not going to have surgical site infections," he said.

"When the wound has closed, the patient's fate has been sealed,"said Dr. Fry. Furthermore, postclosure antibiotics add unnecessary cost to the procedure and contribute to antibiotic resistance--a problem that is increasing in the United States.

In a randomized study of 215 patients undergoing elective colon surgery, all were given intravenous antibiotics, and one group also received oral antibiotics while the other did not. The study showed that using oral and systemic antibiotics together significantly decreased SSI rates in people undergoing surgical resection (Can. J. Surg. 2002;45:173-80).

In a prospective trial examining the effect of oxygen supplementation in elective colon surgery, 500 patients were randomized to receive supplemental oxygen in the operating room and either a fraction of inspired oxygen (FiO2) of 30 or an FiO2 of 80 for 2 hours post operatively. Patients in the higher oxygenation group had fewer postoperative infections, Dr. Fry said (N. Engl. J. Med. 2000;342:161-7).

A higher intraoperative temperature may also decrease rates of infection. In another randomized trial of 200 colon surgery patients, a core temperature of greater than or equal to 34.5° C was maintained in about half of the patients and a core temperature of greater than or equal to 36.5° C was maintained in the other half during surgery. Patients in the lower temperature group had a significantly higher postoperative infection rate (N. Engl. J. Med. 1996;334:1209-15).

Maintaining strict glucose control may be an additional factor that can decrease infection rates in diabetic patients. Dr. Fry cited a prospective study of 2,467 diabetic patients who had open-heart surgery. The 968 control patients received intermittent subcutaneous insulin, and the 1,499 treatment patients received continuous insulin to maintain a glucose level of 200 mg/dL or less. Those in the treatment group had significantly fewer deep sternal wound infections (Ann. Thorac. Surg. 1999;67:352-60).

While SSIs are a common problem, surgeons could be much more proactive in helping to prevent them, he said.

"All of these measures have good evidence that they reduce perioperative infections, but the main challenge is creating systems and procedures that get them done on all patients at the appropriate times." commented Dr John (Jeb) Hallett, vascular surgeon and medical director at the Roper St. Francis Heart and Vascular Center and clinical professor of surgery at the Medical University of South Carolina.

"We have found that compliance takes three key components: (1) education and buy-in by nurses and surgeons, (2) standardized order sets and protocols, and (3) regular review of compliance rates with everyone involved in the patient care pathway from arrival to discharge."