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About the Author:
Deverick J. Anderson, MD, MPH

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Preventing SSIs

Surgical site infections (SSIs) occur in 2% to 5% of patients undergoing inpatient surgery in the United States, but these rates amount to about 500,000 SSIs each year. “While the rate of SSIs is relatively low, the number of these occurrences is high because so many surgeries are performed every year,” says Deverick J. Anderson, MD. “Each SSI has been associated with 7 to 10 additional postoperative hospital days, which increases patients’ risks for other complications.”

Patients with an SSI are at significantly greater risk of death when compared with operative patients without an SSI. It has been estimated that about 77% of deaths among patients with SSIs are directly attributable to the infection. “The costs attributable to SSIs vary depending on the type of operative procedure and the type of infecting pathogen,” Dr. Anderson notes. “Prolonged hospitalizations and the additional therapies required to treat these infections increase costs substantially.” According to published estimates, SSIs are believed to account for up to $10 billion annually in healthcare expenditures.

Prevention Recommendations

A task force appointed by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and other partners has created a concise compendium of recommendations for the prevention of common healthcare-associated infections (HAIs), including SSIs. The recommendations, published in the October 2008 supplement to Infection Control and Hospital Epidemiology, are designed to help hospitals focus and prioritize their efforts to implement evidence-based practices to prevent HAIs such as SSIs.

Several practices are important for preventing SSIs, says Dr. Anderson, who was on the panel that created the compendium recommendations. “Much attention has been paid to the administration of antimicrobial prophylaxis in accordance with evidence-based standards and guidelines.” Prophylaxis should be administered within 1 hour before incision to maximize tissue concentration. Agents should be selected on the basis of the surgical procedure, the most common pathogens causing SSI for a specific procedure, and published recommendations. It is also important to discontinue prophylaxis within 24 hours after surgery for most procedures and within 48 hours for cardiac procedures.

The compendium recommendations also provide guidance on prevention strategies for SSIs during the preoperative, perioperative, and postoperative periods (Tables 1 and 2). “More and more hospitals are getting better at adhering to published guideline recommendations, but patient education during the preoperative period can improve,” Dr. Anderson says. “Patients need to be educated more about their risks for SSIs and informed of the precautions they can take to decrease their risk for these infections. Physicians can provide instructions and information to patients before surgery and describe strategies for reducing SSI risk, such as stopping smoking or controlling their diabetes. Providing preprinted materials to patients can help. Additionally, elective procedures should be delayed until patients improve their modifiable risk factors.”

Get Feedback

According to the compendium recommendations, hospitals should measure and provide feedback to providers on the rates of compliance with process measures. “This includes collecting, analyzing, and reporting data on antimicrobial prophylaxis, proper hair removal, and glucose control,” says Dr. Anderson. “Hospitals need to perform surveillance for SSIs and to provide ongoing feedback to surgical and perioperative personnel and leaders. The efficiency of surveillance can be improved by using automated data and some institutions have been successful using computer-assisted decision-support methodology. This support is potentially expensive and can be time consuming to implement, but the benefits may outweigh the costs. SSIs may be included as part of accreditation requirements, so it behooves hospitals to implement policies and practices aimed at reducing the infection rates.”

When implementing policies and practices, hospitals should assess the reduction of modifiable patient risk factors for SSIs. They should also assess the optimal cleansing and disinfection of equipment and the environment, and the optimal preparation and disinfection of the operative site and the hands of surgical team members. The compendium recommendations also encourage adherence to hand hygiene and traffic control in operating rooms.

Education is Paramount

The education of surgeons and perioperative personnel about SSI prevention is important, according to the compendium recommendations. Dr. Anderson says staff should be knowledgeable about SSI risk factors, outcomes associated with the infection, local epidemiology, and basic prevention measures. “Several educational components can be combined into concise, efficient, and effective recommendations that hospital staff can easily understand and remember. The education of staff should include methods to reduce risk to all patients, patients’ families, surgeons, and perioperative personnel. Just as educational efforts are important when managing patients, they’re also important for the family members who care for them.”

Deverick J. Anderson, MD, MPH, has indicated to Physician’s Weekly that he has worked as a paid speaker for Cubist, and has received grants/research aid from Pfizer and Merck.

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