Surgical site infections (SSIs) are a prevalent issue in healthcare and make up a significant portion of healthcare-associated infections. The Centers for Disease Control and Prevention (CDC) has established criteria defining SSIs as infections linked to operative procedures occurring at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted during surgery [1]. Due to the risks that SSIs pose to patients, surgical teams and facilities need to stay up to date on current prevention guidelines.
Among surgical patients, SSIs constitute the largest fraction of nosocomial infections, making up 38 percent of these cases. It is estimated that SSIs develop in 2 to 5 percent of the more than 30 million patients undergoing surgical procedures each year (approximately 1 in 24 patients) [1]. To improve patient care and prevent avoidable deaths, various organizations like the CDC, the Institute for Healthcare Improvement, and the Surgical Care Improvement Project advocate for specific interventions. Notably, hospitals that implemented programs focusing on appropriate antibiotic use, hair removal techniques, glucose management, and thermoregulation reported a mean 27 percent reduction in SSI rates over one year [2]. Current SSI prevention guidelines cover a wide range of steps that should be taken to minimize risk. These include proper planning for the surgery, patient preparation, and disinfection and hygiene.
Surgical Planning
Timing of surgery: Patients undergoing emergent or urgent surgical procedures face a higher risk of adverse outcomes, including SSI. In some cases, temporary measures can be utilized to convert an emergency procedure into a more elective one or to optimize patient physiology and tissue perfusion [3].
Remote infection: Before elective surgery, patients displaying signs of an active infection at a remote site should complete treatment before surgery, especially if prosthetic material placement is anticipated.
Malnutrition: Hypoalbuminemia increases the risk of SSI six-fold compared to normal albumin levels. However, trials have shown no benefit in delaying surgery to provide total parenteral nutrition to malnourished patients [3].
Minimally invasive versus open approach: Minimally invasive and laparoscopic-assisted procedures are generally associated with lower SSI rates compared to open procedures. For example, the SSI rate in cholecystectomy and colon surgery is significantly lower with laparoscopy [3].
Patient Preparation
Smoking cessation: Smoking is linked to an increased risk of SSI and other complications. The risk for former smokers is intermediate between current smokers and those who have never smoked. Therefore, quitting smoking four to six weeks before elective surgery is recommended to reduce the risk of SSI [4].
Bowel preparation: Bowel preparation before colon surgery has been shown to reduce SSI rates. However, its value in conjunction with intra-abdominal surgeries not involving the colon directly is not proven, and its use is not recommended to reduce the risk of SSI or other infections (e.g., infected prostheses).
Infection Control
Alongside maintaining a clean operating room environment, timely administration of effective preoperative antibiotics and meticulous adherence to operative technique are vital for SSI prevention. Other perioperative infection control interventions, including hand hygiene, use of gloves and other barrier devices by operating room personnel, patient decolonization, skin antisepsis, and hair removal by clipping instead of shaving, can significantly reduce patient contact with microorganisms from hospital personnel, which can be potential sources of SSIs [5].
Hand hygiene and surgical attire: Surgical hand hygiene involves preoperative cleansing of hands and forearms with an antiseptic agent. It’s recommended to use either antimicrobial soap or an alcohol-based hand rub, and all members of the surgical team must practice hand hygiene. Surgical attire, including scrubs, gloves, and barrier devices (masks, caps, gowns, drapes, and shoe covers), should be used according to guidelines issued by the American College of Surgeons as part of SSI prevention [5].
Decolonization and skin antisepsis: Staphylococcus aureus is a bacteria that is often present on human skin. Though it normally does not cause harm, it can become a pathogen when the opportunity arises, and drives many hospital-acquired infections. The optimal approach to S. aureus screening and decolonization is still uncertain. Several studies have shown that preoperative decolonization can reduce SSI rates in colonized surgical patients, particularly those undergoing orthopedic or cardiac procedures. Skin antisepsis is warranted to reduce skin flora burden; the use of chlorhexidine/alcohol-based skin antiseptics is favored over povidone-iodine preparations [5].
In summary, SSI prevention improves surgical outcomes, and providers can rely on published, current guidelines. Timely administration of preoperative antibiotics and meticulous adherence to perioperative infection control measures, including hand hygiene and proper use of barrier devices in the operating room are all important pieces of prevention.
References
1) Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992; 20:271.
2) Anderson DJ, Podgorny K, Berríos-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35:605.
3) Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010; 303:2479.
4) Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003; 238:1.
5) Liu Z, Dumville JC, Norman G, et al. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2018; 2:CD012653.
6) Anderson, DJ, and Sexton, DJ (2022). Overview of control measures for prevention of surgical site infection in adults. UptoDate.