Putting surgical site infection bundles into practice

©Jacob Lund - stock.adobe.com

Table 1

Key points and recommendations

Surgical site infections (SSI) are the most common type of health-care associated infections.¹ Hysterectomy, the most common gynecologic surgery, has been reported to have a SSI rate of 2.7%.² SSIs are further categorized by The Centers for Disease Control and Prevention (CDC) into both incisional SSI and organ-space SSI.³ Two-thirds of gynecological SSIs are superficial incisional infections (vaginal cuff cellulitis)⁴ with a 1.1% rate of deep and organ-space SSI (vaginal cuff abscess, peritonitis, and pelvic abscess) following hysterectomy.² The morbidity and mortality associated with SSI have driven efforts to recognize and address risk factors.⁵ In addition, the Centers for Medicare and Medicaid Services (CMS) now publicly report SSI rates and use them to determine CMS reimbursement by penalizing hospitals if a Medicare patient develops a SSI.⁶ With this additional incentive many hospitals are turning to surgical site infection bundles, which are a compilation of evidence-based and existing guidelines that can be implemented rapidly to facilitate prevention. 

Surgical site infection prevention resources
The American College of Surgeons has developed a free resource, Strong for Surgery, which is a public health campaign to evaluate evidence-based practices to optimize preoperative care prior to surgery and minimize SSI.⁷ The Strong for Surgerywebsite, (https://www.facs.org/quality-programs/strong-for-surgery/about) provides resources including a toolkit for development of presurgical checklists. The focus of the checklists is on four key areas: nutrition, smoking, blood sugar, and medication.

In addition, Pellegrini et al., developed a mnemonic for a gynecologic-specific SSI bundle: WASHING (weight, antibiotic-resistant skin flora, smoking cessation, hygiene, immune deficiency status, nutritional status, glycemic control) to provide assistance in identifying key factors to prevent gynecologic SSI.⁸

Weight
Body mass index (BMI) positively correlates with infections in women undergoing abdominal hysterectomies.⁹ Rates of wound infection range from 8.9%, 4.1%, and 1.4% in morbidly obese, obese, and normal-weight patients, respectively.¹⁰ Although weight loss should not restrict access to an indicated surgery, physicians may counsel patients regarding the benefits of weight loss prior to surgery.¹¹ Obese patients may require a larger dose of prophylactic antibiotics to exceed the same serum and tissue minimum inhibitory concentrations required as in a normal-weight patient. Although clinical data are limited to support a benefit of weight-based dosing, pharmacokinetic studies have demonstrated decreased serum and tissue levels in obese patients who were administered 1 or 2 g of cefazolin.¹² Therefore, the recommended dosage of cefazolin is 3 g if a patient weighs > 120 kg.^11,13

Regardless of weight, antibiotics should be administered within 60 minutes before a surgical incision,⁸ which is typically part of most surgical time-outs. Re-dosing of antibiotics is necessary for any procedure that lasts longer than 2 to 3 hours or when blood loss exceeds 1500 mL. Antibiotic selection is based on type of surgery and wound classification. Prophylactic antibiotic coverage for abdominal gynecologic surgeries includes a cephalosporin to cover Staphylococcus aureusand Streptococcus species.⁸ In addition, we recommend adding the surgical wound classification (SWC) during a structured operative debrief after a gynecologic surgery. SWC is an important predictor of postoperative surgical site infections and this will ensure that correct classification is recorded (e.g., clean contaminated).  

Antibiotic-resistant skin flora, and MRSA
Evaluation of a preoperative history for methicillin-resistant Staphylococcusaureus(MRSA) infection or colonization may reduce risk of post-operative SSI, as 50% of hospital-acquiredS. aureusinfections in the United States are due to MRSA.⁶ If a history of MRSA colonization is identified prior to surgery, it can be treated with a single preoperative dose of vancomycin, 15 mg/kg up to a maximum of 2 g/dose.¹⁴

Smoking
Many complications, including SSI, are more prevalent in smokers.⁷ Because smoking has a detrimental effect on all phases of wound healing,⁷ smoking cessation prior to surgery reduces SSI.¹⁵ Physiologically, smoking cessation may cause increased secretions and more reactive airways in the first 48 to 72 hours, which can interfere with anesthesia. However, recent data have not demonstrated increased surgical risks during acute preoperative smoking cessation.^7,15 Therefore, we encourage our patients to quit smoking as soon as possible, regardless of their surgical date.

Hygiene/skin preparation
Preoperatively, patients should be counseled regarding hygiene. They should not shave the operative site, as this increases risk of infection.¹³ They should also be instructed to shower or bathe the entire body with either a soap or an antiseptic agent such as chlorhexidine at least the night before the surgery. Intraoperatively, hair should not be removed from the incisional site unless it interferes with the surgery. If so, it should be removed immediately before the operation with electric clippers.¹³ Most institutions have policies regarding these preoperative recommendations.  

Antisepsis of the surgical site is integral to prevent SSI. Only povidone-iodine preparation is currently approved by the US Food and Drug Administration for vaginal surgical site antisepsis.^9,14 However, vaginal surgical site antisepsis can be performed with either 4% chlorhexidine gluconate or povidone-iodine before a hysterectomy or vaginal surgery based on patient allergies or surgeon preference. 

Immune deficiency status
Patients with immune deficiency have increased rates of infection⁷ and surgery itself can cause immune suppression. Administering immune-modulating diets preoperatively with supplements such as arginine and fish oil may reduce risk of postoperative infections.^16-18 One evidence-based immune modulating supplementation technique is to prescribe patients an oral supplement (Impact Advanced Recovery®,  Nestlé, 237 mL) three times daily for a total of 5 days prior to surgery.¹⁹

Nutritional status
Malnourished patients have higher rates of complications including postoperative complications, increased mortality, length of hospital stay, and costs.^2,15 Strong for Surgery has a presurgical checklist available to review nutritional interventions. The key focuses of these checklists include measurement of preoperative albumin, assessment of nutritional status, and use of evidence-based nutritional support. An albumin of less than 3 g/dL is associated with a 200% to 300% increase in rates of reoperation and/or death in patients postoperatively. However, albumin may not accurately predict all patients with malnutrition; using the presurgical checklist with assessment of nutritional status can identify patients that require further evaluation by a trained dietician.⁷

Glycemic control
It is important to identify patients pre-operatively that may have undiagnosed diabetes as, by some estimates, there are over 8 million undiagnosed cases of diabetes in the United States.⁸ In addition, known diabetic patients should have adequate glycemic control and blood sugar levels no higher than 200 mg/dL prior to surgery.¹⁴  Preoperative hemoglobin A1C levels of greater than 8.0% may be associated with increased morbidity and longer hospital length of stay.^20,21  Although there are no American Diabetes Association (ADA) recommendations regarding A1C thresholds prior to elective surgical management, Strong for Surgeryrecommends further diabetes management and evaluation if A1C values are > 7.0% or the patient has had a fingerstick reading > 200 mg/dL in the past 2 weeks.⁷ Currently at our institution, patients with known diabetes have an A1C checked prior to surgery, and if it is > 8.0%, elective surgery is delayed. In addition, all patients without a known history of diabetes have a fingerstick blood sugar checked in the preoperative unit the day of surgery, if the blood glucose is > 200 mg/dL, elective surgery is canceled.

Medications 
In the perioperative period, it is imperative to review all medications a patient is taking.

This includes review of anticoagulants, beta-blockers, aspirin, immunosuppressive and herbal medications.⁸ Review of medication is a critical component of not only SSI prevention but also patient perioperative safety. Perioperative medications checklists are also available at Strong for Surgery.⁷

Impact of SSI bundles and checklists
The use of perioperative “bundles” reduces readmission rates and morbidity for surgery including gynecologic surgeries.²² One study demonstrated that implementation of gynecologic perioperative bundles, which included chlorhexidine gluconate-impregnated wipes, patient controlled preoperative warming, aseptic gynecologic skin preparation, maintenance of sterile dressings, intraoperative warming, antibiotic protocol administration, and timely constructive feedback when deviations from the protocol were identified, reduced SSI for hysterectomies from 4.5% to 1.9%.²² Implementation of SSI bundles is greatly facilitated with use of checklists. Both Strong for Surgeryand the World Health Organization offer surgical safety checklists. Enforcing checklists can assist in ensuring vital factors such as performing antibiotic re-dosing administration in the appropriate timeframe as well as monitoring compliance.²³

Disclosures:

Disclaimer: This guest editorial does not necessarily reflect the views of all members of the editorial staff or the board of Contemporary OB/GYN.

References:

• Magill SS, Edwards JR, State M et al., Multistate point-prevalence survey of health care-associated infections. N Engl J Med. March 27, 2014; 370(13):1198-1208. 
• Lake AG, McPencow AM, Dick-Biascoeches MA et al. Surgical site infection after hysterectomy. Am J Obstet Gynecol. November 12, 2013;209(5).
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• Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999;20:725–730.
• Peasah SK, McKay NL, Harman JS et al. Medicare non-payment of hospital-acquired infections: infection rates three years post implementation. Medicare & Medicaid Research Review. 2013; 3(3):E1-E13.
• Strong for Surgery. https://www.facs.org/quality-programs/strong-for-surgery/about. Published 2017. Accessed May 18, 2018.
• Pellegrini JE, Toldeo P, Soper DE et al. Consensus bundle on prevention of surgical site infections after major gynecologic surgery. Obstet Gynecol. January 1, 2017;129(1):51-61.
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• American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 195. Washington, DC: College of Obstetricians and Gynecologists, June 2018.
• Richards JE, Kauffmann RM, Obremskey WT, May AK. Stress-induced hyperglycemia as a risk factor for surgical-site infection in non-diabetic orthopaedic trauma patients admitted to the intensive care unit. J Orthop Trauma. 2013;27:16–21.
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• Halkos ME, Puskas JD, Lattouf OM et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thoracic Cardiovasc Surg. September 2008; 136(3):631-640.
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