According to recent data, surgical site infections (SSIs) are common complications in acute care facilities, occurring in 2% to 5% of patients undergoing inpatient surgery. Approximately 160,000 to 300,000 SSIs occur each year in the United States, making these infections one of the most common and costly healthcare-associated infections (HAIs). “As society continues to age, older patients are increasingly undergoing surgical procedures,” says Keith S. Kaye, MD, MPH. “These patients are particularly vulnerable to SSIs. As surgical advances continue to evolve, we must continue to find ways to further improve our ability to prevent SSIs.”
Studies have shown that as many as 60% of SSIs are preventable if clinicians follow evidence-based guidelines. SSIs account for about 20% of all HAIs in hospitalized patients, and each case is associated with at least 7 days of prolonged hospitalization. Research has indicated that SSIs account for $3.5 billion to $10 billion annually in healthcare expenditures. Dr. Kaye notes that the outcomes and costs attributable to SSIs vary depending on the type of operation and the type of infecting pathogen.
A Welcome Update
In 2008, the Society for Healthcare Epidemiology of America (SHEA) and Infectious Disease Society of America (IDSA) released their Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. The document was designed to help healthcare institutions prioritize and implement strategies to reduce the number of infections. Recently, SHEA and IDSA released an update of these guidelines and published them in Infection Control and Hospital Epidemiology.
The updated evidence-based recommendations are broader and more inclusive than other clinical guidelines that are currently available. They include 15 strategies for prevention that go beyond the standard practices that are required by other national organizations. “Since 2008, much has been learned from clinical trials and studies regarding SSIs,” says Dr. Kaye, who was co-lead author of the guidelines. “The update provides ‘real-world’ strategies for the prevention and surveillance of SSIs.” He notes that the updated recommendations focus on supporting data and aim to avoid relying exclusively on data from randomized control trials.
The SHEA/IDSA update recommends that healthcare professionals adhere to appropriate antimicrobial prescribing practices before and after surgery to optimize outcomes (Table). “Screening for Staphylococcus aureus colonization before surgery and decolonizing patients can be an important method to prevent SSIs in certain settings in certain settings,” Dr. Kaye says. “Studies have demonstrated that preoperative decolonization can improve outcomes, especially for high-risk operations. The guidelines also support the use of alcohol-based skin preparations to minimize SSI risks. The specific type of product—be it chlorhexidine or something else—isn’t as important as it is to use one that is alcohol-based, unless contraindicated.”
The guidelines also recommend following protocols for proper hair removal and controlling blood glucose levels in cardiac patients as strategies to further help reduce the incidence of SSIs. Postoperative surveillance is another key issue addressed in the guidelines. Healthcare professionals are urged to review microbiology reports, patient medical records, and surgeon and patient surveys. They are also recommended to screen for readmissions and returns to the operating room in an effort to prevent SSIs.
SHEA/IDSA also included a special section on implementing the guidelines and stressed using a team-based approach to prevention. “Education on practices to prevent SSIs is essential for senior leadership, physicians, nurses, and patients and families,” says Dr. Kaye. The guidelines recommend engaging a multidisciplinary team that includes senior leadership and a champion physician in a culture of safety. Surgical teams, senior leadership, and patients and families should be routinely educated on prevention techniques and there should be a focus on reducing barriers and improving adherence with evidence-based practices.
Dr. Kaye says that more research is needed to further enhance the management of SSIs. “For example, we need more head-to-head comparisons on the efficacy of preoperative skin preparations,” he says. “We also need studies to help establish if vancomycin or other antibiotics are more effective when given preoperatively as prophylaxis for MRSA. It’s possible that other antimicrobial therapies that are active against MRSA may be more effective in SSI prevention.”
In addition to its recommendations for SSIs, the update of the Compendium of Strategies to Prevent Healthcare- Associated Infections in Acute Care Hospitals also provides guidelines on the prevention of other common HAIs, including Clostridium difficile , MRSA, central line-associated bloodstream infections, and ventilator-associated pneumonia. In addition, the document offers clinicians with an article focused on hand hygiene improvement strategies. “These documents can be a great asset to clinicians as they strive to reduce the burden of HAIs,” Dr. Kaye says.
Anderson DJ, Podgorny K, Berrios-Torres SI, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35:605-627. Available at: http://www.jstor.org/stable/10.1086/676022.
National Healthcare Safety Network. Surgical Site Infection (SSI) Event. Atlanta: Centers for Disease Control and Prevention, 2013. Available at: www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf.
Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S51-S61.
Yokoe DS, Anderson DJ, Berenholtz SM, et al. Introduction to “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates.” Infect Control Hosp Epidemiol. 2014;35:455-459.
Meeks DW, Lally KP, Carrick MM, et al. Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3? Am J Surg. 2011;201:76-83.