infection prevention
By Sue Barnes , RN , CIC , FAPIC
Using a Post-Operative Surgical Site Infection Prevention Bundle to Reduce Risk
Guidelines addressing the prevention of surgical site infections
( SSI ), using a bundle of measures , include those from the Centers for Disease Control and Prevention 1 , the American College of Surgeons , 2 the World Health Organization 3 as well as a nationally accepted protocol called Enhanced Recovery After Surgery ( ERAS ). 4 Each of the SSI prevention guidelines focus on the pre-operative and intra-operative periods , with little or no information regarding the post-operative period . 5 And while the ERAS protocol ( s ) does address the post-operative period , it does not address infection risk in that period . The surgical incision ( s ) does not begin to heal until 48 hours days post-op when epithelialization of the wound occurs , and until then it is possible for contamination to occur which can lead to infection . 6
Wound Closure and SSI Risk
Wound closure is applied during the intraoperative period , but remains in place , and impacts incisional healing and the risk of post-operative SSI . There is wide variation in clinical guidance regarding wound closure and conclusive direction is missing from the current SSI prevention guidelines . Consequently , wound closure is primarily guided by surgeon choice . Wound closure types include non-impregnated suture , antimicrobial impregnated suture , staples , steri-strips , surgical glue ( 2-octyl-cyanoacrylate ) and sometimes a combination of glue over suture or steri-strips . There is evidence that the following wound closure types can increase surgical infections risk : staples , 7 , 8 non-impregnated suture . 9 Alternatively , there is evidence that the following wound closure types reduce surgical infection risk : antimicrobial ( triclosan ) impregnated suture 9 , surgical glue ( 2-octyl-cyanoacrylate ), or a combination of glue over suture . 8
Post-Operative Wound Dressing and SSI Risk
Gauze and tape dressings , the original post-op dressing , were designed to protect the incision from disruption . During the past decade there have been numerous innovations in post-op incisional dressings . Today , these innovative dressings are designed to not only protect the incision , but also promote an optimal healing environment , and reduce the risk for microbial growth . And yet , arguable the most common type of post-operative dressing remains gauze and tape , because as with other post-op procedures , clear direction is missing from the SSI prevention guidelines . Consequently , dressing choice is based mostly on surgeon preference . Innovations in post-op dressings for which there is evidence of reduced infection risk include those that are absorbent , transparent and CHG-impregnated , 10 silver-impregnated , 11 , 12 and negative pressure wound dressings . 13
Post-Operative Bathing and SSI Risk
Directions given to patients after surgery , commonly include a restriction from bathing for 48 to 72 hours , presumably to prevent irritating or macerating the wound , and disturbing the healing environment . However , there is no science supporting this restriction , and reducing hygiene may result in accumulation of sweat and dirt on the body , increasing the risk of wound contamination . Since clear direction regarding post-op bathing is missing from the SSI prevention guidelines , this is commonly left to surgeons ’ discretion . According to one clinical paper which reviewed nine studies involving 2,150 patients , no increased incidence of infection was found in the patients allowed to shower or bathe as a part of their normal daily hygiene before suture removal compared with those who were instructed to keep the site dry until suture removal . 14 Given that all SSI prevention guidelines recommend bathing with chlorhexidine ( CHG ) soap or impregnated CHG wash cloths before surgery , some hospitals are reasonably concluding that post-op bathing with CHG for a few days until the incision begins to heal , is prudent . 15
Nasal Colonization and SSI Risk
Nasal decolonization has long been reported in peer reviewed studies as an important tool when used in a bundle , to reduce the risk of post-operative surgical site infections . However , the studies have all focused only on preoperative application of nasal decolonizing agents . This may be because most of the studies were performed using mupirocin which requires five consecutive days of application , and then provides Staph aureus elimination for up to 87 percent after four weeks , and 48 percent after six months . 16 Now that nasal antiseptics are taking the place of mupirocin due to the immediacy of effect , as well as the emergence of mupirocin-resistant Staph aureus , some hospitals are continuing the application of an alcohol-based nasal antiseptic for a few days until incisional healing begins . 17
Conclusions
While a bundle approach to SSI prevention has been recommended by the existing clinical SSI prevention guidelines , none address the post-operative period of incisional healing . There is evidence to recommend at least four prevention measures that reduce the risk of SSI during the post-operative period :
➊ Wound closure with antimicrobial impregnated suture , surgical glue , or a combination of the two
➋ A post-operative dressing supported by peer-reviewed clinical evidence of efficacy
➌ Bathing / showering post-operative days 1-4 , with 4 percent CHG soap or 2 percent CHG-impregnated bathing cloths
➍ Twice daily nasal decolonization with an alcohol-based nasal antiseptic post-operative days 1-4 .
References :
1 . 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 ( 6 ): 605-627 . doi : 10.1086 / 676022
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