Surgical Site Infections: the international guidelines for best practices and effective actions

Surgical Site Infections: the international guidelines for best practices and effective actions SSIs are the second most common type of adverse event occurring in hospitalised patients. SSIs have been shown to increase mortality, readmission rate, length of stay, and cost for patients who incur them. A review of the medical literature shows that some effective acions reduce the incidence of SSI. These key recommendations have been separated into three phases: preoperative, intra e postoperative. Preoperative: Appropriate use of antibiotics 1) How to Guide: Prevent Surgical Site Infections IHI 2012 Prophylactic antibiotic received within 1 hour prior to surgical incision* Prophylactic antibiotic selection for surgical patients consistent with national guidelines Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients) *Due to the longer infusion time required for Vancomycin, it is acceptable to start this antibiotic (e.g., when indicated because of beta lactam allergy or high prevalence of MRSA) within 2 hours prior to incision. For a correct improvement: Involve pharmacy, infection control, and infectious disease staff to ensure appropriate timing, selection, and duration Assign dosing responsibilities to anesthesia or designated nurse (e.g., pre op holding or circulator) to improve timeliness. 2) The Canadian Patient Safety Institute (CPSI) Getting Started Kit: Prevent Surgical Site Infections Safer Healthcare Now! April 2010 While the necessity and efficacy of preoperative prophylactic antibiotics are not in question, the type, dose, timing, and duration of antibiotic prophylaxis continue to be debated in the literature. Timing All systemic antibiotic infusions must be started and completed within 60 minutes of first incision18, except vancomycin and fluoroquinolones which need to be infused over more time (120 minutes) to avoid Red Man Syndrome. However, vancomycin infusions must be completed no more than 60 minutes prior to first incision. Re dosing of antibiotics may be required during prolonged surgeries (more than 4 hours) in order to maintain therapeutic levels perioperatively. Dosing: There is limited published data on appropriate antimicrobial dosing for prophylaxis. The dosage of the antibiotic needs to be adequate based on the patient s body weight, adjusted dosing weight, or body mass index34. Additional doses may be necessary during prolonged surgery in order to ensure an adequate antimicrobial level until wound closure. Weight Based Dosing Rationale and expert opinion point to the adoption of weight based dosing as an added 1

strategy to lower SSI rates. There is evidence that applying weight based dosing to cefazolin and vancomycin surgical prophylaxis regimens will lower SSI rates among obese patients. However, there are pharmacokinetic considerations that pose challenges when determining adequate dosages of antibiotics in obese patients. However, there is current discussion evolving that questions whether 1 gm of Cefazolin is adequate for normal weight adults and some institution are moving to a standard protocol of giving 2 grams of Cefazolin for all surgical adult patients even though sufficient evidence has not been published at this point. Single Dose Antibiotic Prophylaxis Published literature on antibiotic prophylaxis shows that for non complex and uncomplicated surgical cases a single dose of antibiotic may be sufficient in preventing infections. most consultants believe that postoperative doses are usually unnecessary and can increase the risk of antimicrobial resistance. Yet, there is no definitive evidence that this be adopted as a general rule for all types of surgery, therefore guidelines from international organizations (CDC, NICE, WHO and SHEA) are not emphatic in recommending single dose prophylaxis. Many local institutions are giving prophylaxis up to 24 hours post operatively for cardiac, thoracic, orthopaedic, and vascular surgery. At this point, the literature has not shown whether single dose prophylaxis is equal or superior to 24 hour regimens in preventing surgical infections for all major surgeries. 5) Safer Systems Saving Lives Preventing Surgical Site Infection Version 4 Antibiotics within one hour prior to surgical incision develop and implement a protocol for the use of prophylactic antibiotics administration of a prophylactic antibiotic consistent with national guidelines (see http://etg.hcn.net.au/) discontinuation of prophylactic antibiotics within 24 hours after surgery use responsibilities to anaesthesia or holding area nurse to improve timeliness use visible reminders, checklists or stickers involve pharmacy, infection control and infectious disease staff to ensure appropriate timing, selection and duration of antibiotics. Ensure that prophylactic antibiotic is prescribed as per local antibiotic policy/sign guideline, for the specific operation category (Category 1A) Ensure that the antibiotic is administered within 60 minutes prior to the operation (blade to skin) (Category 1A) 6) CDC Prevention strategies Administer antimicrobial prophylaxys in accordance with evidence based standards and guidelines Administer within 1 hour prior to incision 2hr for vancomycin and fluoroquinolones Select appropriate agents on basis of Surgical procedure Most common SSI pathogens for the procedure Published recommendations Remote infections whenever possible: Identify and treat before elective operation Postpone operation until infection has resolved 2

Discontinue antibiotics within24hrs after surgery end time (48hrs for cardiac)* Redose antibiotic at the 3 hr interval in procedures with duration >3hrs Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30) Give antibiotic prophylaxis to patients before: clean surgery involving the placement of a prosthesis or implant clean contaminated surgery contaminated surgery. Do not use antibiotic prophylaxis routinely for clean non prosthetic uncomplicated surgery. Use the local antibiotic formulary and always consider potential adverse effegcts when choosing specific antibiotics for prophylaxis. Consider giving a single dose of antibiotic prophylaxis intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used. Before giving antibiotic prophylaxis, consider the timing and pharmacokinetics (for example, the serum half life) and necessary infusion time of the antibiotic. Give a repeat dose of antibiotic prophylaxis when the operation is longer than the half life of the antibiotic given. Give antibiotic treatment (in addition to prophylaxis) to patients having surgery on a dirty or infected wound. Inform patients before the operation, whenever possible, if they will need antibiotic prophylaxis, and afterwards if they have been given antibiotics during their operation. Risk assessment for meticillin resistant Staphylococcus aureus (MRSA) screening: Ensure that a clinical risk assessment for meticillin resistant Staphylococcus aureus (MRSA) screening is undertaken (Category 1B) 6) CDC Prevention strategies Nasal screen and decolonize only Staphylococcus aureus carriers undergoing elective cardiac and other procedures (i.e., orthopaedic, neurosurgery procedures withimplants) with preoperative mupirocin therapy Do not use nasal decontamination with topical antimicrobial agents aimed at eliminating Staphylococcus aureus routinely to reduce the risk of surgical site infection. Appropriate hair removal: 1) How to Guide Prevent Surgical Site Infections IHI 2012 When hair must be removed to safely perform the procedure, it should never occur with a razor. It is preferable to use clippers rather than shaving with a razor as this results in fewer surgical site infections. The use of clippers has been found to be the best method in many hospitals, as depilatory creams can cause skin reactions. Staff must be trained in the proper use of clippers because an untrained user can damage the skin. If hair must be removed preoperatively, it is generally recommended that this not occur in the operating room itself, as loose hairs are difficult to control. 3

For a correct improvement: Educate patients not to self shave preoperatively. Remove all razors from the entire hospital. 2) The Canadian Patient Safety Institute (CPSI) Getting Started Kit: Prevent Surgical Site Infections Safer Healthcare Now! Apr 2010 The use of razors (shaving) prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all. According to WHO guidelines, hair should not be removed unless it interferes with the surgical procedure. The literature indicates that clipper use is sufficient for any body part and that razor use is not appropriate for any operative site. Clippers should be used as close to the time of surgery as possible. Hair removal should take place outside of the operating room. The Safer Healthcare Now! SSI faculty recommend that patients be educated not to shave in the vicinity of the incision for one week preoperatively. No hair removal prior to surgery is optimal. If hair removal is necessary, clippers should be used outside of the OR and within 2 hours of surgery. Do not use razors in the vicinity of the surgical area. Patients should shower after clipping due to increased risk of bacterial contamination of the surgical site. For a correct improvement: Involve staff in the selection of clippers Update policy and procedure to include use of clippers instead of razors Remove all razors from the hospital once clippers have been introduced Educate staff on hair removal Educate patients not to shave preoperatively and incorporate this message into the preoperative patient information and surgeon s office communication Ensure that hair is not removed if at all possible; if hair removal is necessary, do not use razors (Category 1A) the main consensus is that the use of razors should be avoided and to ensure that hair removal takes place as close in time to the surgical procedure as possible. It is acknowledged that hair removal prior to surgery may be required in order to enable visualisation of the surgical site during the procedure. If hair removal is necessary then clippers or depilatory creams should be used in preference to razors. Therefore, it is concluded that hair removal should be avoided when possible but if required for a clinical reason, then the use of razors is contraindicated. 5) Safer Systems Saving Lives Preventing Surgical Site Infection Version 4 For many years, it has been known that the use of razors (shaving) prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all. It has also been demonstrated that just as significant as the method of hair removal is the timing of hair removal. It is been recommended that if hair removal is considered necessary then it is performed as close to the time of incision as possible, and that clippers are used instead of razors. Many teams working on this measure find that the use of razors in their own institutions can range from zero to nearly one hundred per cent. For a correct improvement: 4

develop and implement a protocol for appropriate preoperative hair removal educate staff about the evidence for appropriate hair removal where hair must be removed around surgical site, clippers be used rather than razors hair removal should be performed as close to the time of incision as possible educate patients not to self shave preoperatively. Do not remove hair at the operative site unless it will interfere with the operation; do not use razor If necessary, remove by clipping or by use of a depilatory agent Do not use hair removal routinely to reduce the risk of surgical site infection. If hair has to be removed, use electric clippers with a single use head on the day of surgery. Do not use razors for hair removal, because they increase the risk of surgical site infection. Antiseptic cleanse 2) The Canadian Patient Safety Institute (CPSI) Getting Started Kit: Prevent Surgical Site Infections Safer Healthcare Now! Apr 2010 Although preoperative bathing (whole body disinfection) with antiseptic agents has not been shown to reduce the incidence of SSI rates, it has been shown to reduce bacterial counts on the skin. The Safer Healthcare Now! SSI faculty recommend that the skin should be cleansed before surgery with a chorhexidine based solution, preferably with no rinse disposable chlorhexidine gluconate impregnated wash cloths. Skin sensitivities/allergies. Chlorhexidine is well tolerated and has shown a low incidence of hypersensitivity and skin irritation. Rare cases of severe allergic reactions, including anaphylaxis, have been reported. Caution should be exercised to avoid direct contact with the eye, inside of the ear (to avoid vestibular and ototoxicity), or with neural tissue. Ensure that the patient has showered (or bathed/washed if unable to shower) on day of or day before surgery using soap (Category 1B) The NICE guidelines conclude that while there is a consensus of evidence that demonstrates that pre operative showering with detergents or soap is associated with a reduction in SSI there is no evidence to suggest that antiseptics are more effective. No evidence was identified with respect to the optimal timing of preoperative showers prior to surgery or whether more than one shower resulted in increased effect It was therefore concluded based on best practice and expert opinion, that showering should take place on the day of the surgery if possible or otherwise the day before. Advise patients to shower or have a bath (or help patients to shower, bath or bed bath) using soap, either the day before, or on the day of, surgery. 5

Communication to the patient (Patient s involvement) 1) How to Guide: Prevent Surgical Site Infections IHI 2012 The day or night before surgery: Take extra good care of your body. Do not shave near where you will have surgery. Shaving can irritate your skin, which may lead to infection. If you are a man who shaves your face every day, ask your surgeon if it is okay to do so. Keep warm. This means wearing warm clothes or wrapping up in blankets when you go to the hospital. In cold weather, it also means heating up the car before you get in. Keeping warm before surgery lowers your chance of getting an infection. At the time of surgery: Tell the anesthesiologist (doctor or nurse who puts you to sleep for surgery) about all the medications you take. A good way to do this is to bring a written, up to date medication list with you. Let the anesthesiologist know if you have diabetes or high blood sugar, or if family members do. People with high blood sugar have a greater chance of getting infections after surgery. Speak up if someone tries to shave you with a razor before surgery. Ask why you need to be shaved and talk with your surgeon if you have any concerns. Ask for blankets or other ways to stay warm while you wait for surgery. Find out how you will be kept warm during and after surgery. Ask for extra blankets if you feel cold. Ask if you will get antibiotic medicine. If so, find out how many doses you will get. Most people receive only one dose before surgery and are on antibiotics. Provide info about TVP. To prevent surgical site infections, doctors, nurses and other healthcare providers will take several measures to ensure that the surgical site is as clean as possible, including: Cleaning their hands and arms up to the elbows with an antiseptic agent just before the surgery Wearing hair covers, masks, gowns, and gloves during surgery to keep the surgery area clean When indicated, giving you antibiotics before surgery starts Cleaning the skin at the surgery site with a special soap that kills germs How can you and your loved ones safeguard against surgical site infections? Prior to your surgery, discuss other health problems, such as diabetes, with your doctor. These issues could affect your surgery and your treatment. If you smoke, quit. Patients who smoke get more infections. Follow your doctor's instructions for cleaning your skin before your surgery. For example, if your doctor recommends using a special soap before surgery, make sure you do so. Ask if you need to get antibiotics prior to surgery. After surgery, be sure to follow the recommendations below to protect against surgical site infection. Ask your healthcare provider to clean their hands with soap and water or an alcohol 6

based hand rub before they examine you or check your wound. Ensure family and friends clean their hands before and after visiting you. Do not allow visitors to touch the surgical wound or dressings. Make sure you understand how to care for your wound before you leave the medical facility. Always clean your hands before and after caring for your wound. If you have any symptoms of an infection, such as redness and pain at the surgery site, drainage, or fever, call your doctor immediately. Offer patients and carers clear, consistent information and advice throughout all stages of their care. This should include the risks of surgical site infections, what is being done to reduce them and how they are managed. Offer patients and carers information and advice on how to care for their wound after discharge. Offer patients and carers information and advice about how to recognise a surgical site infection and who to contact if they are concerned. Use an integrated care pathway for healthcare associated infections to help communicate this information to both patients and all those involved in their care after discharge. Always inform patients after their operation if they have been given antibiotics. 8) Sign Antibiotic prophylaxis in surgery july 2008 updated aprile 2014 Explain to patients that surgical operations carry risks, one of which is the risk of infection at the site of surgery, known as surgical site infection (SSI). The risk of SSI is different for different surgical procedures. Antibiotic prophylaxis can reduce the risk of surgical site infection. Not all operations require antibiotic prophylaxis and not all surgical site infections are preventable. PREOPERATIVE: Antibiotic prophylaxis carries a small risk of anaphylaxis. overuse of antibiotics can lead to the development of micro organisms that are resistant to certain antibiotics. All surgical departments should have information leaflets for patients about specific surgical procedures. Healthcare professionals should discuss the risks and benefits of antibiotic prophylaxis to reduce the risk of SSI with the patient. Patients should receive preoperative advice and information on how to reduce the risk of SSI. Patients known to carry MRSA should receive information about the associated risks and about modification to procedures that may minimise the risks. POSTOPERATIVE: It is estimated that around 70% of postoperative infections present in the community after discharge. Healthcare professions should give patients advice and information on postoperative wound care and monitoring surgical wound for infection. Local information leaflets should be available. 7

INTRA AND POST OPERATIVE Antiseptic skin preparation 2) Safer Healthcare Now! April 2010 Getting Started Kit: Prevent Surgical Site Infections Chlorhexidine and povidone iodine are the most commonly used antiseptic compounds. While both are safe and effective for skin disinfection, 2% chlorhexidine with 70% isopropyl alcohol (CHG/IPA) has repeatedly been shown to be a more effective surgical skin preparation solution than any other bactericidal agent to which it has been compared. The properties that make chlorhexidine highly effective are a strong affinity for binding to the skin, high antibacterial activity, and prolonged residual effects on rebound bacterial growth. Recent research has shown substantive evidence that alcohol based chlorhexidine antiseptic solution is superior to povidone iodine in preventing surgical site infections. Caution with Alcohol Based Solutions Fire hazard. Fires in the OR can have devastating consequences for both patients and staff. While fires in the OR are extremely rare, alcohol based antiseptics are flammable, therefore the Safer Healthcare Now! faculty recommend that the following precautions be taken when using alcohol based antiseptic skin prep solutions: Staff need to be educated before using a CHG alcohol solution on how to be safe and effective in their application of a flammable skin prep agent Avoid dripping or pooling of alcohol based antiseptic solutions on sheets, padding, positioning equipment, adhesive tape, and on or under the patient(umbilicus, groin)55. Ensure that the liquid has completely dried by evaporation 3 minutes is usually sufficient26, 55. Areas with excess hair may take longer to dry. Healthcare facilities utilizing alcohol based surgical prep solutions should develop protocols that ensure and document that the applied solution is completely dry before draping the patient (i.e. add to preoperative surgical checklist). Single use applicators should be used to apply flammable prep agents. For head and neck procedures, use an applicator with less volume to avoid excess. This limits the amount of pooling on or under the patient5. Surgical team members need to communicate to each other when a flammable prep agent is used. Ensure that 2% chlorhexidine gluconate in 70% isopropyl alcohol solution is used for skin preparation (if patient sensitive, use povidone iodine) (Category 1A) Use appropriate antiseptic agent and technique for skin preparation Prepare the skin at the surgical site immediately before incision using an antiseptic (aqueous or alcohol based) preparation: povidone iodine or chlorhexidine are most suitable. If diathermy is to be used, ensure that antiseptic skin preparations are dried by evaporation and pooling of alcohol based preparations is avoided. 8

Maintenance of pre operative glucose control 2) The Canadian Patient Safety Institute (CPSI) Getting Started Kit: Prevent Surgical Site Infections Safer Healthcare Now! Apr 2010 Based on the evidence, The Safer Healthcare Now! SSI faculty recommend that postoperative blood glucose levels be checked on all surgical patients who are diabetic or have risk factors for diabetes. Teams are encouraged to apply glucose control to surgical populations as directed by your local organization. Ensure that the diabetic patient s glucose level is kept <11mmol/l throughout the operation (Category 1B) Control blood glucose level during the Immediate post operative period (cardiac)* Measure blood glucose level at 6AM on POD#1 and #2 with procedure day = POD#0 Maintain post op blood glucose level at <200mg/dL Do not give insulin routinely to patients who do not have diabetes to optimise blood glucose postoperatively as a means of reducing the risk of surgical site infection. Perioperative normothermia 1) How to Guide: Prevent Surgical Site Infections IHI 2012 The medical literature indicates that patients undergoing colorectal surgery have a decreased risk of SSI if they are not allowed to become hypothermic during the perioperative period.11 Anesthesia, anxiety, wet skin preparations, and skin exposure in cold operating rooms can cause patients to become clinically hypothermic during surgery. There is evidence to show that preventing hypothermia is beneficial in reducing other complications, and it clearly is more comfortable for patients For a correct improvement: Prevent hypothermia at all phases of the surgical process. Use warmed forced air blankets preoperatively, during surgery, and in PACU. Use warmed fluids for IVs and flushes in surgical sites and openings. Use warming blankets under patients on the operating table. Use hats and booties on patients perioperatively. Adjust engineering controls so that operating rooms and patient areas are not permitted to become excessively cold overnight, when many rooms are closed. Measure temperature with a standard type of thermometer. 2) The Canadian Patient Safety Institute (CPSI) Getting Started Kit: Prevent Surgical Site Infections Safer Healthcare Now! Apr 2010 General and neuraxial anesthesia impairs thermoregulatory control. Consequently, most patients who are not actively warmed will become hypothermic intra and postoperatively. The medical literature suggests that patients undergoing surgery have a decreased risk of surgical site infection i normothermia is maintained during the 9

perioperative period. Anesthesia, anxiety, wet skin preparations, and skin exposure in cold operating rooms can all contribute to hypothermia. Normothermia (core temperature 360C 380C) should be maintained preoperatively, intraoperatively, and in PACU by implementing any combination of the following: Pre printed order sets warmed forced air blankets when surgery is expected to last >30 minutes Warmed Intravenous fluids for abdominal surgeries of >1 hour duration Warmed lavage liquids for colorectal surgery Increase the ambient temperature in the operating room to 200C Hats and booties on patients during surgery Pre warming should be initiated between 30 minutes to 2 hours prior to major surgery. 3) NHS Health Protection Scotland Aprile 2012 Ensure that the patient s body temperature is maintained above 36 C (excludes cardiac patients) (Category 1A) 5) Safer Systems Saving Lives Preventing Surgical Site Infection Version 4 Ensuring the patient is warm, dry and comfortable is a fundamental aspect of patient care. Saving Lives project recommends use warmed forced air blankets preoperatively, during surgery and in the recovery room use warmed IV fluids increase the ambient temperature in the operating room use warming blankets under patients on the operating table use hats and booties on patients perioperatively. Maintain immediate postoperative normothermia Haemoglobin saturation 3) NHS Health Protection Scotland Aprile 2012 Ensure that the patient s haemoglobin saturation is maintained above 95% (or as high as possible if there is underlying respiratory insufficiency) (Category 1B) Sterile wound 3) NHS Health Protection Scotland Aprile 2012 Ensure that the wound is covered with a sterile wound dressing at the end of surgery (Category 1A) Ensure that the wound dressing is kept in place for 48 hours after surgery unless clinically indicated (Category II) 5) Safer Systems Saving Lives Preventing Surgical Site Infection Version 4 To comply with the SSI bundle, teams will develop a surgical wound dressing protocol and record compliance with this protocol during hospital stay. 10

Operating Room (OR) Traffic Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient Incise drapes 3)NHS Health Protection Scotland Aprile 2012 The use of incise drapes in the prevention of surgical site infection (SSI) (Category II) Hand hygiene 3) NHS Health Protection Scotland Aprile 2012 Ensure that hand hygiene is performed immediately before every aseptic dressing change (WHO Moment 2) (Category 1A) An important resource for implementation 11