Exploring the evidence, measures to reduce surgical site infections

Surgical site infections (SSIs) account for approximately 20 percent of all hospital-acquired infections, and nearly 60 percent of these infections are preventable. Established guidelines help reduce the rate of SSIs, but are these guidelines effective?

“The session, “Surgical Site Infections: Is My Cloth Hat Really Killing People?,” arose originally from the ongoing surge in practices that are not necessarily founded in science,” said Keith Candiotti, M.D., Professor of Anesthesiology and Internal Medicine at the University of Miami. He reviewed the recent literature to distinguish “what’s fact and what’s not” regarding interventions to reduce the rate of SSIs.

Keith Candiotti, M.D., discussed the prevention of surgical site infections.

There is no question that bacterial contamination is common, but whether that contamination translates to an increased rate of SSIs is not supported by the literature. For example, preoperative bathing with chlorhexidine does reduce skin bacterial count, but there is no evidence that it reduces the rate of SSIs. In other instances, the broadening of practices to prevent SSIs is considered to be detrimental. For example, the rate of SSIs is reduced by the use of MRSA bundles that include a vancomycin-containing antibiotic. However, the use of vancomycin in MRSA-negative patients is associated with an increased rate of SSIs.

One area of debate is the association between O.R. attire and the rate of SSIs. The Association of periOperative Registered Nurses (AORN) published attire recommendations in 2014. “Many traditional practices are no longer supported by The Joint Commission, and there is little evidence to support most of the policies in place,” said Dr. Candiotti.

He discussed additional studies that have shown no correlation between attire and the rate of SSIs. One clothing item that has received extensive attention is the O.R. cap. Several studies have been done to compare the rates of SSIs with disposable bouffants, disposable skull caps and cloth skull caps, resulting in equivalent rates of SSIs .

“Overall, there is no substantiation that attire affects the rate of SSIs. Common sense would seem to prevail, and we should look elsewhere for solutions,” said Dr. Candiotti.

Those solutions include practicing good hand hygiene and wiping anesthesia equipment often. Double-gloving is recommended for airway management, with removal of the outer gloves as soon as possible after intubation. Dr. Candiotti suggested that, when the outer glove is removed, it should be pulled off and over the laryngoscope to further avoid contamination. Additionally, he was surprised to find that the under-surface of a flip-top drug vial is not sterile, and the top should be wiped before drawing up an injection. Other evidence-based “easily achievable endpoints” include:
• Control the patient’s glucose level
• Use antibiotics appropriately
• Keep patients normothermic
• Use supplemental oxygen (80 percent)
• Maintain euvolemia
• Limit allogenic transfusions

According to Linda Groah, M.S.N., RN, CNOR, CEO of the Association of periOperative Registered Nurses, AORN guidelines are being updated and are scheduled to be available on the AORN website for public comment in January. She encouraged anesthesiologists to provide feedback.

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