Surgical Site Infection Prevention: A Review PDF

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/367218095 Surgical Site Infection Prevention: A Review Article in JAMA The Journal of the American Medical Association · January 2023 DOI: 10.1001/jama.2022.24075 CITATIONS...

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/367218095 Surgical Site Infection Prevention: A Review Article in JAMA The Journal of the American Medical Association · January 2023 DOI: 10.1001/jama.2022.24075 CITATIONS READS 177 4,016 3 authors: Jessica L. Seidelman Christopher Mantyh Duke University Duke University Medical Center 112 PUBLICATIONS 890 CITATIONS 236 PUBLICATIONS 9,619 CITATIONS SEE PROFILE SEE PROFILE Deverick J Anderson Duke University Medical Center 416 PUBLICATIONS 13,731 CITATIONS SEE PROFILE All content following this page was uploaded by Christopher Mantyh on 26 January 2023. The user has requested enhancement of the downloaded file.  Clinical Review & Education JAMA | Review Surgical Site Infection Prevention A Review Jessica L. Seidelman, MD, MPH; Christopher R. Mantyh, MD; Deverick J. Anderson, MD, MPH Multimedia IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient’s endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient’s immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose 150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. Author Affiliations: Duke Center for Antimicrobial Stewardship and CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of Infection Prevention, Duke University School of Medicine, Durham, North patients undergoing surgery and are associated with longer hospital stays than patients with Carolina (Seidelman, Anderson); no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of Department of Surgery, Duke chlorhexidine gluconate plus alcohol–based skin preparation agents, decolonization with University School of Medicine, intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk Durham, North Carolina (Mantyh). procedures, controlling for perioperative glucose concentrations, and using negative pressure Corresponding Author: Deverick J. Anderson, MD, MPH, DUMC, wound therapy can reduce the rate of surgical site infections. Box 102359, Durham, NC 27710 ([email protected]). JAMA. 2023;329(3):244-252. doi:10.1001/jama.2022.24075 Section Editor: Mary McGrae McDermott, MD, Deputy Editor. A surgical site infection is defined as infection following an operation at an incision site or adjacent to the surgical Methods incision.1 Infections occur in approximately 0.5% to 3% of patients undergoing surgery2-4 and are among the most prevalent We searched PubMed, Google Scholar, and the Cochrane database health care–acquired infections.5-7 Surgical site infections are re- for English-language studies of pathogenesis, clinical presenta- sponsible for approximately $3.5 billion to $10 billion in US health tion, and prevention of surgical site infections published from Janu- care costs annually.8,9 Compared with patients without surgical site ary 1, 2016, when guidelines were most recently published by the infections, those with them remain in the hospital approximately 7 World Health Organization, to September 15, 2022. In addition, we to 11 days longer7,10; 1 study involving 177 706 postsurgical patients manually searched the references of selected articles for addi- reported that 78% were readmitted as a result of the infection.11 This tional relevant publications. We prioritized randomized trials, sys- review summarizes current evidence-based interventions for pre- tematic reviews, meta-analyses, clinical practice guidelines, and ar- vention of surgical site infection that are applicable to the majority ticles pertinent to general medical readership. Of 94 studies of operations (Box). identified, 69 were included, consisting of 14 randomized trials, 19 244 JAMA January 17, 2023 Volume 329, Number 3 (Reprinted) jama.com © 2023 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Duke Medical Center Library User on 01/17/2023  Surgical Site Infection Prevention—A Review Review Clinical Review & Education systematic reviews, 12 meta-analyses, 4 clinical practice guide- lines, 17 cohort studies, and 3 cross-sectional studies. Box. Commonly Asked Questions How can the generalist clinician help in preventing surgical site infections? Discussion and Observations The the generalist can help patients improve modifiable characteristics associated with increased risk of surgical site Pathophysiology infections. such as helping obese patients lose weight, assisting Surgical site infection acquisition depends on several factors, patients who have diabetes with optimal glucose control, namely, exposure to bacteria and the host’s ability to control the and assisting with smoking cessation. inevitable bacterial contamination of the incision. They are typically Is there a threshold hemoglobinA1C value above which caused by bacteria inoculated into the surgical site at the time of surgical site infections are more common and surgery surgery. Approximately 70% to 95% are caused by the patient’s should be delayed? endogenous flora.12 The most common organisms are Staphylo- Perioperative hyperglycemia in patients with or without diabetes coccus aureus, coagulase-negative Staphylococcus, and Escherichia is associated with surgical site infections, and randomized clinical coli.13 In some patients, introduction of only 100 colony-forming trials support perioperative glucose control as an evidence-based practice to decrease risk of surgical site infection. In contrast, there units of bacteria into the surgical site can cause infection.14 How- are no randomized clinical trials that have found a clear association ever, exogenous sources of contamination during surgery such as between a specific hemoglobin A1c cutoff value and surgical site bacteria transmitted from surgical personnel or heater-cooler units infections. However, patients with higher hemoglobin A1c levels can also lead to infections. will likely have higher perioperative glucose values and glucose Pathogens that cause infection vary by surgical location. The levels that are harder to control. most common pathogens are components of skin flora such as S What therapies can prevent a surgical site infection? aureus and Streptococcus species. In contrast, infections follow- Numerous strategies are currently recommended as outlined in ing gastrointestinal procedures are typically associated with this review. Six are supported by randomized clinical trials: enteric organisms such as Enterococcus species and E coli.15 Over- (1) do not remove hair at the surgical site unless necessary; all, S aureus is the most common cause of infection; for example, (2) decolonization with intranasal antistaphylococcal agent and S aureus was associated with 24% of nonsuperficial surgical site antistaphylococcal skin antiseptic prior to high-risk procedures (eg, cardiothoracic, orthopedic); (3) use a chlorhexidine infections in a cohort study including 32 community hospitals in gluconate-alcohol antiseptic agent for skin preparation; the southeastern US.4 Although methicillin-resistant S aureus (4) maintain normothermia intraoperatively; (5) control (MRSA) was previously more likely to cause surgical site infec- perioperative glucose values between 110 and 150 mg/dL; tions than methicillin-sensitive S aureus (MSSA), the rate of and (6) use incisional negative pressure wound MSSA-derived infections from 2013 to 2018 was higher (0.07 per dressings. 100 procedures) than the rate of MRSA infections during the same period (0.05 per 100 procedures). 4 MRSA surgical site infections lead to worse clinical outcomes than those caused by Some of these risk factors associated with surgical site infec- less resistant pathogens.10 Specifically, compared with MSSA sur- tion are modifiable, such as hyperglycemia, obesity, and tobacco use. gical site infections, those due to MRSA were independently asso- Other factors are nonmodifiable, such as age, which must be con- ciated with 5.5 additional hospital days (95% CI, 1.97-9.11).10 E coli sidered when deciding on the surgical intervention for the and Enterococcus species respectively cause approximately 9.5% patient.26,49 and 5.1% of all surgical site infections.13 Clinical Presentation Factors Associated With Surgical Site Infection The median time to diagnosis of surgical site infection varies by Factors associated with surgical site infection include older age, procedure.50 For example, S aureus infection is typically diag- presence of immunosuppression, obesity, diabetes, effectiveness nosed a median of 14 days after plastic surgery, 24 days after gen- of antimicrobial prophylaxis, surgical site tissue condition (such as eral orthopedic surgery, and 28 days after orthopedic surgery the presence of foreign material), and degree of wound contami- where a prosthetic device was inserted. A surgical site infection is nation (Table 1 and Table 2). For example, a national study of suspected when purulent drainage is present at the incision site more than 387 000 patients found that for most surgery types, or when there is evidence of an abscess involving the surgical rates of surgical site infection were increased in patients with bed. Physical examination findings such as systemic signs of obesity.21 The rates of surgical site infection following mastec- infection (eg, fevers, rigors), local erythema, wound dehiscence, tomy among 16 473 patients increased with body mass index pain, nonpurulent drainage, or induration are the most common. (BMI), calculated as weight in kilograms divided by height in However, the presence or absence of these symptoms varies meters squared. Those with a BMI of 20 to 25 had a surgical site depending on factors such as surgical site, host, and time from infection rate of 4.66%; BMI of more than 30 to 40, 7.06%; and surgery to presentation. For example, fevers can be present in BMI of more than 40, 10.58%. Similarly, after 29 603 laparo- 14% of patients with a chronic prosthetic joint infection but up to scopic cholecystectomy procedures (urgency not specified), the 75.5% of patients if the etiology of the prosthetic joint infection is infection rate increased with BMI: 8.57% with a BMI of 20 to 25; hematogenous.51 Articular effusion and swelling may be present 10.62% with a BMI of 30 to 40; and 17.11% with a BMI of more in 29% to 75% of prosthetic joint infections of the knee,52 and than 40. delayed wound healing, wound dehiscence, or wound drainage jama.com (Reprinted) JAMA January 17, 2023 Volume 329, Number 3 245 © 2023 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Duke Medical Center Library User on 01/17/2023  Clinical Review & Education Review Surgical Site Infection Prevention—A Review Table 1. Modifiable and Nonmodifiable Patient-Related Factors Associated With Surgical Site Infections Factor Pathophysiology Patient-related, modifiable Diabetes Hyperglycemia impairs the innate immune system and promotes glycosylation of proteins, which compromises wound healing.16 Diabetes can lead to higher perioperative glucose levels and hyperglycemia that is more difficult to treat.17 Immunosuppressive Immunosuppressive clinical conditions or medications diminish the inflammatory medications and conditions phase of wound healing.18,19 Malnutrition Malnutrition can decrease collagen synthesis, granulation formation in surgical wounds, and result in poor tissue healing. Hypoalbuminemia weakens innate immunity by prompting macrophage apoptosis and diminishing macrophage activation. Low albumin also accelerates the seepage of interstitial fluid into the surgical wound and promotes general tissue edema.20 Obesity Adipose tissue has less blood flow, which inhibits the delivery of oxygen and antibiotics.21-23 Preoperative infections Prior to elective surgery, recognize and treat all infections (even if they are distant from the surgical site).24 Tobacco use Tobacco use causes vasoconstriction, which can progress to alterations in collagen metabolism, decreased inflammatory response, and relative ischemia.25 Patient-related, nonmodifiable Age The skin’s basement membrane and dermis thin with increasing age, and the skin loses its reserve of cutaneous blood vessels and nerves that diminish wound healing.26,27 History of prior skin and soft A history of skin and soft tissue infections may be indicative of issues with inherent tissue infections immunity and propensity for infection.28 History of radiation therapy Treatment with radiation induces underlying tissue injury and inhibits wound healing. Table 2. Modifiable Operation–Related Factors Associated With Surgical Site Infections Factor Pathophysiology Airborne contamination Raising the amount of microorganisms in the operating room environment provides additional opportunity for surgical site infection. Most of the airborne pathogens are generated by persons in the operating room and their movements.29,30 Anticoagulation Anticoagulants may generate continual oozing of the incision and slow wound healing.31 Blood transfusions Blood transfusions impair macrophage activity and influence infection risk.32 Decreased tissue Diminished tissue oxygenation lends itself to decreased oxidative killing by neutrophils oxygenation and impaired tissue healing from depleted epithelialization, neovascularization, and collagen formation. Low oxygen settings can curtail the efficacy of perioperative antibiotics.33,34 Foreign material Foreign material stimulates inflammation at the surgical site and raises the risk of surgical site infection.35,36 Operation length Longer operative time is associated with higher damage to wound cells, wound contamination, and exposure to the outside environment.37 Perioperative hypothermia Perioperative hypothermia weakens immune system protection against surgical wound contamination: vasoconstriction leads to impaired tissue perfusion and less access for key immune cells, less motility of key immune cells, and decreased scar formation.38 Postoperative Cellular functions of bactericidal activity, leukocyte adherence chemotaxis, and hyperglycemia phagocytosis are enhanced by insulin and glycemic control, suggesting a direct relation between elevated blood glucose and cellular function deficits.39 This relationship is observed in patients with and without a diagnosis of diabetes. Surgical technique Wound healing is decreased by leaving behind devitalized tissues, inadvertent entry into hollow viscera, inadequate blood supply maintenance, rough manipulation of tissue, misplaced drains and sutures, and unsuitable postoperative wound care.40 Wound care Wounds that remain uncovered following surgery can be contaminated, or uncontrolled drainage can diminish the integrity of the surrounding skin.41,42 Wound contamination from Wound classification delineates the degree of contamination of a surgical wound at the patient’s own flora time of the operation.43 Skin preparation and perioperative antibiotic administration reduce but do not eliminate the introduction of microorganisms at the surgical site.44,45 Shaving leads to microscopic cuts in the skin that can become niduses for bacteria to multiply.40 Without appropriate drapes and barrier devices, bacteria from hair follicles and deeper skin layers can recolonize the surgical site. Wound contamination from Transition of microorganisms from the surgical personnel’s shoes, mouths, or body can operating room personnel contaminate surgical wounds.14 Microorganisms from the hands of health care workers in the operating room can move onto the patient and operating field if personnel do not perform appropriate handwashing or gloving.14,46,47 Wound contamination from Sterilization eliminates all microorganisms on the surfaces of surgical instruments. surgical instruments Using insufficiently sterilized tools can lead to pathogen transmission.48 may accompany up to 44% of prosthetic joint infections.53,54 100%. 55 Joint stiffness has a reported sensitivity of 20.5% The presence of a sinus tract or purulent drainage has a specificity and specificity of 99% in patients with a hematogenous source of between 97% and 100% and a positive predictive value of of prosthetic joint infection. 56 Many of the aforementioned 246 JAMA January 17, 2023 Volume 329, Number 3 (Reprinted) jama.com © 2023 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Duke Medical Center Library User on 01/17/2023  Surgical Site Infection Prevention—A Review Review Clinical Review & Education Table 3. Surgical Site Infection Prevention Strategies From Prospective Studies Intervention Type of studies Absolute or median value RR or OR (P value) Preoperative Do not remove hair at the Meta-analysis Razor vs clippers: RR, 1.64 (.005) surgical site unless the of 19 RCTs 4.4% (84 of 1889) presence of hair will affect and 6 vs 2.5% (46 of 1834) the procedurea quasi-randomized Razor vs depilatory cream: RR, 2.28 (.02) trials59 7.8% (68 of 868) vs 3.6% (26 of 725) Razor vs none: RR, 1.82 (.03) 4.2% (34 of 819) vs 2.1% (19 of 887) Decolonize surgical Meta-analysis Decolonization vs none: RR, 0.41 (