Surgical Site Infection Prevention and Control

1. Introduction

A surgical site infection (SSI) is an infection that occurs in the wound created by an invasive surgical procedure within 30 days following the surgery. Surgical site infections (SSIs) are the most common type of health-acquired infection (HAI), making up 14-25% of HAIs (Fan et al.,2014). SSIs occur in a third of all surgical patients (WHO, 2018). According to Fan et al., 2014, approximately 2-5% of patients who have undergone an operation have gotten an SSI. These infections increase the rates of patient morbidity and mortality. They are linked with around 33% of postoperative deaths worldwide (Hegy et al.,2021). The integration of prevention measures perioperatively helps prevent SSIs. This paper explores SSI prevention and control, challenges facing SSI prevention, control, and management, and makes recommendations for more effective strategies in preventing these infections.

2. Impact on the patient and clinical workplace

SSIs have huge impacts on the patient and the clinical workplace. They prolong the hospital stay, consequently increasing the cost of care and contributing to the high personal, facility, state, and national healthcare expenditure. These increased costs are often an economic burden. In a study of 723,490 surgical procedures resulting in 6,891 SSIs, the additional length of stay on average was 9.7 days and extra expenses for care were $20,842 per admission (Graf et al., 2014).

SSIs are linked to a bad reputation for the associated facilities, therefore, fewer surgical patients. SSIs in patients manifest as a purulent discharge from the wound, painful spreading erythema, edema, fever, foul odor, and an abscess visible on direct examination (WHO, 2018). The risk of death is double for patients who develop an SSI. These patients are 60% more likely to spend time in the intensive care unit and five times more likely than non-infected patients to be readmitted to the hospital (Algado- Sellés et al., 2022). Patients may suffer long-term disability following an SSI. The prolonged suffering and treatment can adversely affect a patient’s mental health.

3. Chain of infection

A surgical site infection occurs when a pathogenic microorganism in the healthcare environment gains access to a susceptible host through a chain of transmission. A chain of infection comprises an infectious agent, a reservoir for the agent, a portal of escape from the reservoir, a transmission mechanism, and a portal of entry. A study performed in China showed that Escherichia Coli, Staphylococcus aureus, and Pseudomonas aeruginosa are the most common pathogens associated with SSIs (Fan et al., 2014). They are either found on the skin and penetrate the wound or acquired from external objects like medical instruments. Most SSIs are caused by body flora.

The reservoir is the habitat where the bacteria live, grow and multiply. Some of the reservoirs for SSIs are healthcare workers’ (HCWs) hands, environmental surfaces, surgical instruments, an infected patient, and skin (Wilson, 2019). After the bacteria have grown and multiplied, it requires a portal of exit from the reservoir. The bacteria may exit the reservoir through the skin, body fluids, the gastrointestinal tract, or the respiratory system by coughing or sneezing. A transmission mode is necessary to transfer the pathogen from the reservoir to the host. The transfer may be through direct contact with the reservoir, such as a surgical instrument containing the infectious agent. It may also occur when the HCWs’ hands containing the pathogen touch the susceptible host. The portal of entry provides the pathogen access to the host. For SSIs, the pathogen enters the host through an open surgical incision.

A susceptible host lacks sufficient resistance to this pathogenic agent when exposed. Some risk factors predisposing a patient to SSIs include comorbidities, a weakened defense mechanism, and impaired nutritional status (Wilson, 2019). A patient using immunosuppressants is also susceptible. The ongoing exposure to hospital- acquired antibiotic-resistant bacteria and increased contact with health personnel put the patients at risk for SSIs. Entry of the pathogen into the susceptible host completes the chain of transmission, and the patient is said to be infected.

4. Infection prevention and control measures

 4.1 Standard and Special precautions

Standard and special precautions cause a break in the chain of transmission, consequently preventing infection and spread of SSIs. Standard precautions minimize the risk of transferring bloodborne and other pathogens from known and unknown sources by body fluids, excretions such as urine and feces, broken skin like an open wound, and mucous membranes like the oral cavity (Wilson, 2019). There are seven components of standard precautions. The first is hand hygiene, and it involves decontamination of hands before and after touching something or someone and following the removal of gloves. The World Health Organization (WHO) (2018) describes the appropriate method of surgical hand preparation for the surgical team with an alcohol-based hand rub to prevent SSIs if the gloves are punctured. Covering cuts and abrasions with a waterproof dressing is the second component. The appropriate use of personal protective equipment (PPE) is necessary. Another component is sharps’ safety. It includes proper handling and disposal of sharps and reporting any incidents. Under this precaution, facilities should ensure staff receives hepatitis B vaccination. Other precautions include safe handling of clinical waste, correct decontamination of used equipment such as surgical instruments, and maintaining a safe environment (Wilson, 2019). WHO (2018) emphasizes the importance of maintaining a clean perioperative environment. They recommend proper waste management in the theatre and correct equipment decontamination to prevent and control SSIs.

Special precautions include droplet precautions, airborne precautions, and contact (Wilson, 2019). They protect the person from microorganisms spread through droplets, air, or contact. Microorganisms causing SSIs can be spread by droplets from the respiratory tract of an infected person, through contact, and rarely, by air. Airborne and droplet precautions involve wearing surgical masks and isolation of infected patients. Contact precautions comprise the use of PPEs and hand hygiene. In addition to the standard precautions, these precautions should be adhered to to prevent the spread of SSIs.

4.2 Perioperative measures

The WHO (2018) developed an evidence-based care bundle for SSI prevention. They are divided into preoperative, intraoperative, and postoperative preventive measures.

4.2.1 Preoperative measures.

The preoperative guidelines are to be observed before surgery. WHO (2018) recommends that the patient bathes or showers with soap before surgery to reduce the bacteria load, especially around the incision site. They recommend the use of intranasal mupirocin ointment in surgical patients with nasal carriage Staphylococcus aureus, beginning one day before the surgery until four days postoperatively. Optimal administration of surgical antibiotic prophylaxis within 2 hours pre-incision while considering the drug’s half-life was proven beneficial in controlling SSIs. The WHO (2018) guidelines recommend a combination of preoperative oral antibiotics and mechanical bowel preparation to prevent SSIs in patients undergoing colorectal surgery. Shaving preoperatively is strongly discouraged because it creates an incision for resident bacteria to enter internal organs. If necessary, hair removal should be done with electric clippers.

According to the WHO (2018), surgical site preparation should be done using an alcohol-based chlorhexidine gluconate antiseptic solution for surgical patients. Prevention of SSIs involves eliminating the factors that predispose the patient to infection. In preventing SSIs, administering oral or enteral multiple nutrient-enhanced nutritional formulas in underweight patients who undergo major surgical operations should be considered. Adult patients under general anesthesia with tracheal intubation for surgery should receive an 80% fraction of inspired oxygen intraoperatively and in the immediate postoperative period for 2-6 hours to minimize the risk of SSIs. (WHO, 2018). Maintenance of normothermia during surgery has proven beneficial in preventing SSIs. The WHO, therefore, recommends the use of warming devices in theatre. High blood glucose levels create a favorable environment for bacteria to thrive. Protocols for perioperative glycemic control for all patients undergoing surgery prevent SSIs.

4.2.2 Intraoperative measures.

Intraoperative measures are undertaken during the surgical procedure. WHO (2018) recommends using goal-directed fluid therapy to maintain normovolemia. HCWs should use sterile gowns in the operating room. Abdominal surgical procedures account for a high percentage of SSIs. The surgical team should use wound protective devices to prevent SSIs during abdominal surgery. Irrigating an incisional wound using aqueous povidone-iodine solution should be done before closing it. Prophylactic negative pressure wound therapy should be used on closed high-risk wounds. The WHO (2018) guidelines suggest using triclosan-coated sutures to lessen SSI risk, independent of the type of surgery.

4.2.3 Postoperative Measures.

Postoperative measures are applied immediately after surgery until discharge from the facility. After detailed research, the WHO (2018) advised against some practices done before to prevent SSIs postoperatively. They reported that prolonging antibiotic prophylaxis after the surgery had no proven benefits for the patient. They discouraged using advanced dressing instead of standard dressing for closed wounds. Prophylactic antibiotics due to the presence of a wound drain should not be used to prevent SSIs. A wound drain should only be removed when there is a clinical indication. These guidelines result from detailed research and have proven beneficial in managing and preventing SSIs.

5. Organizational issues that underpin infection prevention and control policy and practice in Hong Kong.

The Centre for Health Protection (CHP) (2020) Department of Health Hong Kong provides a detailed guide to infection prevention and control in the clinical setting. They emphasize using precautions to prevent and control infections, encourage facilities to implement safe work systems, and use infection prevention checklists as tools for audit. They suggest that clinical settings perform risk management and develop policies and plans based on the identified risks. They recommend ongoing staff training and education. They require facilities to establish mechanisms to identify, report, and manage infection prevention and control-related incidents. They advise facilities to comply with relevant legislation and reporting requirements. This guide promotes SSI prevention and control in Hong Kong hospitals.

The CHP Hong Kong set up the Scientific Committee on infection prevention. They advise the CHP on the biological basis of infection control and surveillance to protect medical personnel, patients, and the community from communicable diseases (CHP, 2020). They revise strategies for the public health management of transmissible diseases and their predisposing factors in health facilities, community institutions, and government departments.

6. Relevant policies and public health guidance

HAIs have increased significantly, consequently increasing government expenditure on healthcare. The Hong Kong CHP has established infection prevention and control (IPC) policies to manage them. They recommended an agreed minimum allocation of IPC resources. They suggest having a multidisciplinary Infection Control team and at least one infection control nurse for 250 beds (CHP, 2019). The guidelines state that surveillance programs should guide infection control practices. The Government of the Hong Kong SAR has formed a High-Level Steering Committee to fight antimicrobial resistance (CHP,2019). Antibiotic-resistant bacteria such as Methicillin-resistant Staphylococcus aureus are notorious for causing SSIs. These policies are essential in preventing and controlling SSIs.

7. Audit, surveillance, and risk management

7.1 Audit.

Audit refers to the comparison of actual practice against set standards (Wilson, 2019). It involves the formal examination of the facilities and individual infection control practices. They assist in identifying gaps in infection control and lead to effective mitigation practices, therefore improving the standards of care. Audits monitor compliance among HCWs and identify potential areas of improvement. Nessim et al. (2012) study identified that audit and giving individual feedback in SSI prevention and control practices resulted in better practices by HCWs. They report that audits and feedback enabled the HCWs recognize that SSI prevention is a shared responsibility. They should be done at least every six months. Infection prevention audits form a basis for quality improvement plans.

7.2 Surveillance.

Surveillance is the ongoing systematic gathering, analysis, and interpretation of information related to infectious diseases for planning and implementing their prevention and control. SSI monitoring requires active patient-based surveillance. Surveillance for SSIs is done for thirty or ninety days, depending on the operative procedure category (Centers for Disease Control and Prevention, 2022). Reporting SSIs is part of surveillance. Hong Kong CHP requires that hospital surveillance systems be connected to public health systems. Wloch et al. (2020) study reveals the implications of surveillance in reducing SSIs. They assert that ongoing surveillance accompanied by improved care result in a reduced risk for infection.

7.3 Risk Management.

Risk management is a proactive approach to identifying, assessing, and prioritizing infection risk to avoid or reduce adverse events (Wilson, 2019). Its purpose is to protect the patients and health personnel. Risk management has several steps. Risk analysis is the first step, and it is the structured approach to reducing risk. Risk assessment refers to identifying the hazard and the conditions they occur. These pathogens occur as resident flora on the patients’ skin, environment, medical equipment, health personnel, and other patients. The potential adverse effects are the clinical manifestations of an SSI. SSIs’ risk management involves deciding on the necessary precautions and implementing them. Risk communication is vital in the clinical workplace. Facilities are tasked with communicating the risks to their staff and training them to prevent and control SSIs. A team that is well informed in SSI risk management is better equipped to eliminate and reduce these infections. Risk monitoring then follows to assess the effectiveness of the control measures. After this, an audit is performed to check if the risks are managed. Spina et al. (2018) study found that risk management resulted in significant decreases in SSIs after spine surgery.

8. Challenges and recommendations

Noncompliance to the standard precautions and SSI prevention and control measures is a significant challenge. Mukamurenzi (2019) study revealed that many surgical team members did not adhere to preventive measures such as hand hygiene. Many respondents did not wash their hands for the required 3-5 minutes. The operating room doors remained open despite the recommendation to ensure closed doors during a surgical procedure to minimize the risk of infection. Surgical team members donned insufficient personal protective equipment, leaving the plastic apron and goggles. Another study in Hong Kong reported low adherence to stethoscope disinfection, with 31 out of 335 stethoscopes samples found carrying Staphylococcus aureus (Chau et al., 2010). Facilities should have continuous training of staff and periodic audits of their infection prevention practices. The SSI care bundle and standard precautions should be emphasized in the academic curriculum to equip incoming nurses with this knowledge. An operative checklist should also be available in the operating room to ensure the SSI infection prevention protocols are followed.

The shortage of workers has been a challenge in healthcare (Morikane et al.,2021). It leads to an increased workload on the workforce, leaving little to no time for workforce training. Training the medical team on infection prevention strategies is critical in implementing these practices. The lack of SSI mitigation education derails the efforts. Facilities should ensure they have an adequate workforce to aid in creating time for employee training on the recommended practices. These training programs will keep them updated on evidence-based practices and serve as a basis for appraisal. Poor working conditions lead to a high rate of turnover. They include salary issues, inadequate personal protective equipment, an inconducive working environment, lack of incentives, and communication challenges (Morikane et al., 2021). The more experienced nurses are lost, consequently increasing costs due to recruitment and training expenses. They use up resources that would otherwise be directed towards prevention and managing SSIs. Replacement nurses’ skills need honing and are below standards compared to the others. A high turnover rate hampers the SSI prevention and control efforts. Facilities should maintain a suitable working environment and fair remuneration to retain their staff. They should provide incentives to boost staff morale. Adequate personal protective equipment should be available at all times to protect both the patient and HCWs.

Other SSI management challenges are insufficient policies and procedures and a lack of knowledge about SSI care bundles and prevention and control policies (Morikane et al.,2021). The government at the local and national levels should develop adequate laws to encourage SSI prevention and control. They should disseminate this information to the relevant employees. Nurses and other medical practitioners should embrace continuous learning and regularly update their SSI prevention and control knowledge.

Knowledge deficit and lack of responsibility on the patient’s part is another challenge facing SSI prevention and control (Morikane et al., 2021).The patient may ignore preoperative instructions, for example, refusing to shower before the operation. Education of patients on the rationale of bathing before the surgical procedure increases adherence and responsibility. HCWs should emphasize the importance of following the postoperative instructions.

Poor leadership and teamwork. Good leadership in the operating room is critical in the success of SSI preventive measures (Morikane et al., 2021). Good leaders lead by example and inspire their juniors to follow the prevention and control measures. Teamwork is essential in identifying gaps in infection prevention and acting on them. There should be a qualified person in charge of infection prevention in every operating room to ensure that the SSI care bundle and standard precautions are followed. Burden et al. (2018) suggests that nurses, physicians, surgeons, and anesthetists should collaboratively implement the infection prevention and control measures perioperatively.

9. Conclusion

Despite being preventable, surgical site infections are the most common nosocomial infections. They are associated with prolonged recovery after surgery and increased mortality rates. This paper discusses the standard and special precautions and describes the WHO guidelines in preventing and controlling SSIs. The Hong Kong Centre for Health Protection provides a guide to infection prevention to help decrease the incidence of SSIs. Risk management plays a huge role in mitigating SSIs and eliminating or reducing the risks. Audit and surveillance are essential in ensuring adherence to the preventive measures and maintaining these practices.

There are challenges experienced in the management of SSIs. This paper recommends continuous employee training to improve on SSI infection prevention. It suggests that facilities perform regular surveillance and audits to ensure compliance with the infection prevention measures. A sufficient workforce and good working conditions are recommended to aid in the efforts to improve SSI prevention and control. It emphasizes patient education and a collaborative team approach to ensure strict adherence to the SSI care bundle. Healthcare workers, facilities, the government should apply these recommendations to improve the standards of care and reduce the incidence of SSIs.


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