The American Journal of Surgery (2015) 209, 1107-1110
Editorial Opinion
Two senior surgeons’ view: prevention of surgical site infection associated with colorectal operations KEYWORDS: Surgical site infection; Colorectal surgery; Bowel preparation; Perioperative antibiotics
Abstract Preventing surgical site infection is perhaps the most direct method of decreasing medical expenses. The following is an attempt at comprehensive ways of decreasing surgical site infection as well as decreasing patient discomfort. Ó 2015 Elsevier Inc. All rights reserved.
Surgical site infection (SSI) associated with colorectal surgery is very expensive. Prescriptive methods of process (Surgical Care Improvement ProjectdSCIP) have been largely ineffective in reducing SSI in a number of commonly performed operations.1,2 The incidence of SSI in colorectal surgery, even in a large SCIP series (15,444 colorectal surgeries of 60,853 total SCIP operations), remained stuck at 14%.3 In low anterior resections reported rates are as high as 20%, and the cost of a single SSI may rise to tens of thousands of dollars when organ space infection is involved4 (some as high as 50,000 to 60,000). In addition to reducing patient harm, these data suggest that reduction of colorectal operation associated SSI can effect significant cost saving.5 Although the majority of data focuses on colon and rectal surgery, the same attention to detail will decrease the incidence of noncolorectal SSI. Reduction in hospital-acquired infection has been the target of clinicians hoping to avoid patient harm, and of payors attempting to lower the overall cost of medical care in the United States. SSI is now the most common and costly hospital-acquired infection.6 Despite the increasing
attention directed toward the application of uniform processes of surgical care, changes in surgical process such as SCIP have not shown the hope for decrease in surgical wound infections.3,7 Penalties against institutions, and now surgeons, to get their attention about ‘‘avoidable’’ SSI complications, have not yet been shown to be effective, and SSI risk stratification is in its infancy with respect to punitive economic strictures. A recent exhaustive review of all SSIs with recommendations and strategies for prevention has been published by the Society for Healthcare Epidemiology of America, in association with the Infectious Disease Association of America, and should be studied by those wishing a detailed review with comprehensive bibliography.8 In this brief review, the authors stress those strategies and processes that can be instituted relatively easily (although with strict adherence), and which, when combined and considered in toto, are likely to reduce SSIs associated with ‘colorectal surgery’ but may also be beneficial to all operations. Most of these recommendations have a strong foundation in clinical and/or experimental evidence. Personal preferences are so noted.
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-617-248-1602; fax: 11-617-2481603. E-mail address: [email protected] Manuscript received September 17, 2014; revised manuscript September 29, 2014
Preoperative preparation
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.10.024
The patient should be nutritionally adequate with a serum albumin of at least 3.3 and preferably 3.5 or better. If the procedure is elective, nutritional supplementation for as
1108 few as 3 to 5 days will improve outcome.9 Supplementation for greater than 7 days in a depleted patient will certainly do so.10,11 The surgeon must balance this advantage against the urgency of operation. 1. Skin preparation: Although the majority of colorectalrelated SSIs are caused by gut bacteria, we feel that a given hospital’s preoperative skin preparation regimen should be applied to colorectal operations for purposes of maintaining uniformity and to also minimize the occurrence of infections caused by skin flora in noncolorectal procedures as well. For elective operations, we recommend the use of chlorhexidine cloths from axillae to groins twice in the 2 days before operation.12 When this cannot be assured, we recommend washing the patient in the holding area. 2. ‘‘Prophylactic parenteral antibiotics’’ have been shown to be particularly effective in decreasing SSI, and are considered the practice standard for certain operations, for example, joint replacement and cardiac surgery. They are particularly effective in colorectal operations.13 The timing, dose, and choice of antibiotics are very important, as the patient’s weight, institutional antibiogram, blood loss, and operative time must all be taken into account. Briefly, antibiotic infusion should be started and be completed within the 60 minutes before skin incision (with certain exceptions), dosage should be increased for patients having body mass index greater than 30, and redosing should be considered, depending on the antibiotic’s half-life, or when there has been excessive blood loss.14–16 There are no data supporting the use of prophylactic antibiotics after the conclusion of the operation. 3. ‘‘Preoperation bowel preparation’’ for elective operations has been controversial. It is now clear that mechanical bowel preparation alone offers no protection with regard to SSI, but several studies demonstrate efficacy when combined with the administration of nonabsorbable antibiotics.17–22 Concerns about a possible increased incidence of Clostridium difficile infection in patients who have undergone such bowel preparation are overblown.23–25 There are no data with respect to the use of nonabsorbable antibiotics without mechanical preparation of the bowel. It is our recommendation that all compliant patients scheduled for elective colorectal operations undergo mechanical bowel preparation combined with nonabsorbable antibiotics, in addition to parenteral prophylactic antibiotics. 4. There is now compelling experimental and clinical evidence that the incidence of SSI can be reduced by ‘‘maximizing wound O2 tension.’’26–29 Maintenance of intraoperative normothermia by means of warming intravenous fluids and the use of warming fluid or air blanket systems is the standard of care for abdominal operations. There are also data supporting the efficacy
The American Journal of Surgery, Vol 209, No 6, June 2015 of ‘‘preoperative’’ warming in maintaining intraoperative normothermia, further reducing the risk of infection.30,31 It is quite possible that these two interventions, preoperative warming and increased FiO2, operate synergistically to maintain a high tissue oxygen that results in fewer SSIs. We recommend the application of both modalities in all operations. Warming and continued administration of O2 should be maintained for 2 hours in the post-anesthesia care unit. Ideally, breathing mask could be used in extubated patients, but they might find this unacceptable, and a simple O2 humidified mask should be applied for at least 2 hours. 5. Traditional mechanical ‘‘handwashing’’ with antibacterial agents is gradually being replaced by hand rubs with both aqueous and alcohol-containing solutions. A number of comparative studies show little difference among these techniques.32–34 Our only recommendation is that the surgical team pays close attention to the manufacturers’ directions when using the newer techniques.
In the Operating Room
1. ‘‘The skin should never be shaved.’’ If hair removal is necessary, clipping should be performed outside the operating room. Chlorhexidine–alcohol, povidine iodine, or povidine–alcohol can be used for skin preparation. There appears to be a slight advantage of chlorhexidine–alcohol over povidine–iodine for all operations, although less so in colorectal operations.35,36 We prefer chlorhexidine–alcohol for alcohol’s immediate universal bactericidal properties, and the combination with the longer lasting chlorhexidine, especially when the latter has been used with previous cloth washes. It is extremely important to allow the prepared area to dry completely for both antibacterial and fire safety reasons. 2. ‘‘The skin incision’’ is usually made with a scalpel rather than electrosurgical energy. Because there is a dearth of compelling studies favoring one method over the another,37,38 and there is considerable variability with regard to the energy sources and management of electrosurgery, we strongly favor cold steel. 3. Protection of the wound during operation is important. The data with respect to skin incise drapes are not conclusive, but only the ones with antibacterial adhesive should be used.8 There is Level I evidence, however, with respect to the efficacy of wound protectors in both open and minimally invasive operations.39 We strongly recommend their use. A personal practice is to add antibiotic-soaked lap pads and/or towels to the wound edges as well.
J.E. Fischer and R. Weintraub Prevention of surgical site infection 4. ‘‘Glove breakage’’ occurs in a high percentage of operative cases. Between 8% and 50% of gloves have been shown to be perforated by 2 hours after the commencement of surgery.40,41 Although the effect of these events on SSI has been shown to be partially mitigated by the use of parenteral prophylactic antibiotics, we recommend that all members of the operative team change their gloves after 2 hours of operating. 5. Closure of the abdominal incision is a critical part of the operation. In a December 7, 2012 update of a multicentered collaboration coordinated by the Joint Commission’s Center for Transforming Healthcare, each of the cooperating high-volume centers had found that there was no agreement among the surgeons within each center about the process of closure (http://www. centerfortransforminghealthcare.org/assets/4/6/SSI_ storyboard.pdf). In an early report from one of these institutions, a separate closure kit, and change of gloves for the whole team, was employed in the ‘‘colon bundle,’’ and the colorectal SSI rate was significantly reduced.42 After a period of television monitoring at the Cambridge Health Alliance, we realized that keeping a clean part of the instrument table was inadequate to maintain bacteriologic separation. It simply did not work. We then instituted a policy of considering abdominal closure as a new and separate procedure. After completion of the gastrointestinal phase of the operation and return of the bowel to the peritoneal cavity, ‘‘all’’ cover towels, protectors, light handle covers, electrosurgery handle, instruments, and Mayo stand are removed from the field. All members of the team change gowns and gloves, the patient is redraped, and a new ‘‘closure kit’’ is uncovered and used as if beginning a new operation. We monitor our colorectal operations to ensure continued compliance. This is our surgical version of aviation’s ‘‘black box.’’43 We noticed a considerable decrease in SSI in 2012 and 2013 as compared with the previous 6 years.
Practice technique Close the skin with a fine continuous subcuticular 5.0 suture. Steristrips are placed, and a Xeroform dressing covers the wound. The wound will never have a dressing placed in more sterile conditions than in the operating room. There is no advantage in changing the dressing on the floor, in bed, often without sterile preparation, unless the patient becomes febrile. Leave the wound dressing on until seeing the patient in the office, provided the dressing has remained clean. Other surgeons may prefer to examine the wound daily.
Immediate Postoperative Care This should be considered an extension of the preoperative and operative care outlined in the previous sections. In
1109
addition to the usual cautions about maintaining hemodynamic stability and tissue perfusion with appropriate hemodynamic monitoring and fluid administration, it is important to maintain normothermia and increased oxygenation as previously described.
Wound Management in Contaminated Cases There are almost as many methods of managing obvious wound contamination as there are surgeons. In some cases, it may be preferable to leave the wound open or plan for a delayed closure.
Personal practice of contaminated wounds One practice is to do a primary closure over a Blake 19 drain. After the wound is closed, fill the Blake drain with wide spectrum antibiotic, clamp it, and after 2 hours release the clamp and place the drain to suction. Leave the drain in place for 10 days, because that is when suppuration usually occurs. Finally, a recent ‘‘JAMA Surgery’’ article reported in a large prospective randomized trial44 that the use of preventive bundle in both colorectal and most likely noncolorectal surgery will reduce surgical costs by decreasing superficial SSIs and postoperative sepsis. Interestingly, no significant difference was observed in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs between the match groups.
Conclusions Despite some advances, SSI remains a major cause of injury, morbidity, financial loss, and even death. That associated with colorectal operations has been particularly difficult to prevent, and has been resistant to a number of process improvements. In this presentation, we have described those processes of care that have been proven by experimental and clinical evidence to have been effective in reducing the rate of SSI in colorectal surgery and by extension noncolonic surgery. By concentrating on these precepts, agreeing to a common colorectal bundle including them, and otherwise reducing variance, surgical teams should be able to reduce their colorectal surgery SSI rate, and by extension, noncolonic surgical wound infection rate. Josef E. Fischer, M.D.* Department of Surgery, Harvard Medical School, 29 Commonwealth Avenue, Suite 110, Boston, MA 02116, USA Ronald Weintraub, M.D. Department of Surgery, Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA
1110
References 1. Stulberg JJ, Delaney CP, Neuhaser DV, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479–85. 2. Hawn MT. Surgical care improvement: should performance measures have performance measures? JAMA 2010;303:2527–8. 3. Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg 2011;254:494–9; discussion, 499–501. 4. Madoff RD, Melton GB. Anterior and low anterior resection of rectum. In: Fischer JE, editor. Mastery of Surgery. 6th ed., Vol. 2. Philadelphia, PA: Lippincott Williams &Wilkins; 2012 Chapter 164, p 1739. 5. Stone PW, Kunches L, Hirschhorn L. Cost of hospitaldassociated infections in Massachusetts. Am J Infect Control 2009;37:210–4. 6. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101–14. 7. Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479–85. 8. 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;35:605–27. 9. Holter AR, Fischer JE. The effects of perioperative hyperalimentation on complications in patients with carcinoma and weight loss. J Surg Res 1977;23:31–4. 10. Campos AC, Mequid MM. A critical appraisal of the usefulness of perioperative nutritional support. Am J Clin Nutr 1992;55:117–30. 11. Buzby GP. Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutritional Cooperative Study Group. N Engl J Med 1991;325:525–32. 12. Lipke VL, Hyott AS. Reducing surgical site infections by bundling multiple risk reduction strategies and active surveillance. AORN J 2010;92:288–96. 13. Nelson RI, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2009:CD001181. 14. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281–6. 15. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195–283. 16. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol 2011;117:877–82. 17. Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg 2010;252:514–9. 18. Poth EJ. Historical development of intestinal antisepsis. World J Surg 1982;6:153–9. 19. Robson MC, Krizek TJ, Heggers JP. Biology of surgical infection. Curr Probl Surg; 1973:1–62. 20. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg 2002;45:173–80. 21. Fry DE. Colon preparation and surgical site infection. Am J Surg 2011;202:225–32. 22. Bellows CF, Mills KT, Kelly TN, et al. Combination of oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials. Tech Coloproctol 2011;15:385–95.
The American Journal of Surgery, Vol 209, No 6, June 2015 23. Krapohl GL, Phillips LR, Campell Jr DA, et al. Bowel preparation for colectomy and risk of Clostridium difficile infection. Dis Colon Rectum 2011;54:810–7. 24. Hunt TK, Hopf HW. High inspired oxygen fraction and surgical site infection. JAMA 2009;302:1588–9. 25. Belda FJ, Aguiler L, Garcia de la Asuncion J, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 2005;294:2035–42. 26. Greif R, Akca O, Horn EP, et al. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med 2000; 342:161–7. 27. Hopf HW, Hunt TK, West JM, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 1997; 132:997–1004. 28. Meyerhoff CS, Wettersley J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery. JAMA 2009;302:1543–50. 29. Quadan M, Akca O, Mahid SS, et al. Perioperative supplemental oxygen therapy and surgical site infection; a meta-analysis of randomized controlled trials. Arch Surg 2009;144:359–66. 30. Wong PF, Kumar S, Bohra A, et al. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007;94:421–6. 31. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Treatment and Temperature Group. N Engl J Med 1996;334:1209–15. 32. Parienti JJ, Thibon P, Heller R, et al. Hand-rubbing with aqueous alcoholic solution versus traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA 2002;288:722–7. 33. Nthumba PM, Stepita-Poenaru E, Poenaru D, et al. Cluster-randomized, cross over trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 2010;97:1621–8. 34. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev 2009:CD004288. 35. Alexander JW, Fischer JE, Boyajian M, et al. The influence of hairremoval methods on wound infections. Arch Surg 1983;118:347–52. 36. Darouche RO, Wall Jr MJ, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical site antisepsis. N Engl J Med 2010;362:18–26. 37. Charoenkwan K, Chotirosniramit N, Rerkasem K. Scalpel versus electrosurgery for abdominal incision. Cochrane Database Syst Rev 2012; 6:CD005987. 38. Molgat YM, Pollack SV, Hurwitz JJ, et al. Comparative study of wound healing in porcine skin with CO2 laser and other surgical modalities: preliminary findings. Int J Dermatol 1995;34:42–7. 39. Edwards JP, Ho AL, Tee MC, et al. Wound protectors reduce surgical site infections: a meta-analysis of randomized controlled trials. Ann Surg 2012;256:53–9. 40. Misteli H, Weber WP, Reck S, et al. Surgical glove perforation and the risk of surgical site infection. Arch Surg 2009;144:553–8. 41. Kojima Y, Ohashi M. Unnoticed glove perforation during thoracoscopic and open thoracic surgery. Ann Thorac Surg 2005;80:1078–80. 42. Cina R, Dankbar E, Lovely J, et al. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience. J Am Coll Surg 2013;216:23–33. 43. Lewis GH, Vaithianathan R, Hockey PM, et al. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Q 2011;89:4–38. 44. Keenan JE, Speicher PJ, Thacker JK, et al. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 2014;149:1045–52.
©2015 Elsevier
Editorial Opinion
Two senior surgeons’ view: prevention of surgical site infection associated with colorectal operations KEYWORDS: Surgical site infection; Colorectal surgery; Bowel preparation; Perioperative antibiotics
Abstract Preventing surgical site infection is perhaps the most direct method of decreasing medical expenses. The following is an attempt at comprehensive ways of decreasing surgical site infection as well as decreasing patient discomfort. Ó 2015 Elsevier Inc. All rights reserved.
Surgical site infection (SSI) associated with colorectal surgery is very expensive. Prescriptive methods of process (Surgical Care Improvement ProjectdSCIP) have been largely ineffective in reducing SSI in a number of commonly performed operations.1,2 The incidence of SSI in colorectal surgery, even in a large SCIP series (15,444 colorectal surgeries of 60,853 total SCIP operations), remained stuck at 14%.3 In low anterior resections reported rates are as high as 20%, and the cost of a single SSI may rise to tens of thousands of dollars when organ space infection is involved4 (some as high as 50,000 to 60,000). In addition to reducing patient harm, these data suggest that reduction of colorectal operation associated SSI can effect significant cost saving.5 Although the majority of data focuses on colon and rectal surgery, the same attention to detail will decrease the incidence of noncolorectal SSI. Reduction in hospital-acquired infection has been the target of clinicians hoping to avoid patient harm, and of payors attempting to lower the overall cost of medical care in the United States. SSI is now the most common and costly hospital-acquired infection.6 Despite the increasing
attention directed toward the application of uniform processes of surgical care, changes in surgical process such as SCIP have not shown the hope for decrease in surgical wound infections.3,7 Penalties against institutions, and now surgeons, to get their attention about ‘‘avoidable’’ SSI complications, have not yet been shown to be effective, and SSI risk stratification is in its infancy with respect to punitive economic strictures. A recent exhaustive review of all SSIs with recommendations and strategies for prevention has been published by the Society for Healthcare Epidemiology of America, in association with the Infectious Disease Association of America, and should be studied by those wishing a detailed review with comprehensive bibliography.8 In this brief review, the authors stress those strategies and processes that can be instituted relatively easily (although with strict adherence), and which, when combined and considered in toto, are likely to reduce SSIs associated with ‘colorectal surgery’ but may also be beneficial to all operations. Most of these recommendations have a strong foundation in clinical and/or experimental evidence. Personal preferences are so noted.
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-617-248-1602; fax: 11-617-2481603. E-mail address: [email protected] Manuscript received September 17, 2014; revised manuscript September 29, 2014
Preoperative preparation
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.10.024
The patient should be nutritionally adequate with a serum albumin of at least 3.3 and preferably 3.5 or better. If the procedure is elective, nutritional supplementation for as
1108 few as 3 to 5 days will improve outcome.9 Supplementation for greater than 7 days in a depleted patient will certainly do so.10,11 The surgeon must balance this advantage against the urgency of operation. 1. Skin preparation: Although the majority of colorectalrelated SSIs are caused by gut bacteria, we feel that a given hospital’s preoperative skin preparation regimen should be applied to colorectal operations for purposes of maintaining uniformity and to also minimize the occurrence of infections caused by skin flora in noncolorectal procedures as well. For elective operations, we recommend the use of chlorhexidine cloths from axillae to groins twice in the 2 days before operation.12 When this cannot be assured, we recommend washing the patient in the holding area. 2. ‘‘Prophylactic parenteral antibiotics’’ have been shown to be particularly effective in decreasing SSI, and are considered the practice standard for certain operations, for example, joint replacement and cardiac surgery. They are particularly effective in colorectal operations.13 The timing, dose, and choice of antibiotics are very important, as the patient’s weight, institutional antibiogram, blood loss, and operative time must all be taken into account. Briefly, antibiotic infusion should be started and be completed within the 60 minutes before skin incision (with certain exceptions), dosage should be increased for patients having body mass index greater than 30, and redosing should be considered, depending on the antibiotic’s half-life, or when there has been excessive blood loss.14–16 There are no data supporting the use of prophylactic antibiotics after the conclusion of the operation. 3. ‘‘Preoperation bowel preparation’’ for elective operations has been controversial. It is now clear that mechanical bowel preparation alone offers no protection with regard to SSI, but several studies demonstrate efficacy when combined with the administration of nonabsorbable antibiotics.17–22 Concerns about a possible increased incidence of Clostridium difficile infection in patients who have undergone such bowel preparation are overblown.23–25 There are no data with respect to the use of nonabsorbable antibiotics without mechanical preparation of the bowel. It is our recommendation that all compliant patients scheduled for elective colorectal operations undergo mechanical bowel preparation combined with nonabsorbable antibiotics, in addition to parenteral prophylactic antibiotics. 4. There is now compelling experimental and clinical evidence that the incidence of SSI can be reduced by ‘‘maximizing wound O2 tension.’’26–29 Maintenance of intraoperative normothermia by means of warming intravenous fluids and the use of warming fluid or air blanket systems is the standard of care for abdominal operations. There are also data supporting the efficacy
The American Journal of Surgery, Vol 209, No 6, June 2015 of ‘‘preoperative’’ warming in maintaining intraoperative normothermia, further reducing the risk of infection.30,31 It is quite possible that these two interventions, preoperative warming and increased FiO2, operate synergistically to maintain a high tissue oxygen that results in fewer SSIs. We recommend the application of both modalities in all operations. Warming and continued administration of O2 should be maintained for 2 hours in the post-anesthesia care unit. Ideally, breathing mask could be used in extubated patients, but they might find this unacceptable, and a simple O2 humidified mask should be applied for at least 2 hours. 5. Traditional mechanical ‘‘handwashing’’ with antibacterial agents is gradually being replaced by hand rubs with both aqueous and alcohol-containing solutions. A number of comparative studies show little difference among these techniques.32–34 Our only recommendation is that the surgical team pays close attention to the manufacturers’ directions when using the newer techniques.
In the Operating Room
1. ‘‘The skin should never be shaved.’’ If hair removal is necessary, clipping should be performed outside the operating room. Chlorhexidine–alcohol, povidine iodine, or povidine–alcohol can be used for skin preparation. There appears to be a slight advantage of chlorhexidine–alcohol over povidine–iodine for all operations, although less so in colorectal operations.35,36 We prefer chlorhexidine–alcohol for alcohol’s immediate universal bactericidal properties, and the combination with the longer lasting chlorhexidine, especially when the latter has been used with previous cloth washes. It is extremely important to allow the prepared area to dry completely for both antibacterial and fire safety reasons. 2. ‘‘The skin incision’’ is usually made with a scalpel rather than electrosurgical energy. Because there is a dearth of compelling studies favoring one method over the another,37,38 and there is considerable variability with regard to the energy sources and management of electrosurgery, we strongly favor cold steel. 3. Protection of the wound during operation is important. The data with respect to skin incise drapes are not conclusive, but only the ones with antibacterial adhesive should be used.8 There is Level I evidence, however, with respect to the efficacy of wound protectors in both open and minimally invasive operations.39 We strongly recommend their use. A personal practice is to add antibiotic-soaked lap pads and/or towels to the wound edges as well.
J.E. Fischer and R. Weintraub Prevention of surgical site infection 4. ‘‘Glove breakage’’ occurs in a high percentage of operative cases. Between 8% and 50% of gloves have been shown to be perforated by 2 hours after the commencement of surgery.40,41 Although the effect of these events on SSI has been shown to be partially mitigated by the use of parenteral prophylactic antibiotics, we recommend that all members of the operative team change their gloves after 2 hours of operating. 5. Closure of the abdominal incision is a critical part of the operation. In a December 7, 2012 update of a multicentered collaboration coordinated by the Joint Commission’s Center for Transforming Healthcare, each of the cooperating high-volume centers had found that there was no agreement among the surgeons within each center about the process of closure (http://www. centerfortransforminghealthcare.org/assets/4/6/SSI_ storyboard.pdf). In an early report from one of these institutions, a separate closure kit, and change of gloves for the whole team, was employed in the ‘‘colon bundle,’’ and the colorectal SSI rate was significantly reduced.42 After a period of television monitoring at the Cambridge Health Alliance, we realized that keeping a clean part of the instrument table was inadequate to maintain bacteriologic separation. It simply did not work. We then instituted a policy of considering abdominal closure as a new and separate procedure. After completion of the gastrointestinal phase of the operation and return of the bowel to the peritoneal cavity, ‘‘all’’ cover towels, protectors, light handle covers, electrosurgery handle, instruments, and Mayo stand are removed from the field. All members of the team change gowns and gloves, the patient is redraped, and a new ‘‘closure kit’’ is uncovered and used as if beginning a new operation. We monitor our colorectal operations to ensure continued compliance. This is our surgical version of aviation’s ‘‘black box.’’43 We noticed a considerable decrease in SSI in 2012 and 2013 as compared with the previous 6 years.
Practice technique Close the skin with a fine continuous subcuticular 5.0 suture. Steristrips are placed, and a Xeroform dressing covers the wound. The wound will never have a dressing placed in more sterile conditions than in the operating room. There is no advantage in changing the dressing on the floor, in bed, often without sterile preparation, unless the patient becomes febrile. Leave the wound dressing on until seeing the patient in the office, provided the dressing has remained clean. Other surgeons may prefer to examine the wound daily.
Immediate Postoperative Care This should be considered an extension of the preoperative and operative care outlined in the previous sections. In
1109
addition to the usual cautions about maintaining hemodynamic stability and tissue perfusion with appropriate hemodynamic monitoring and fluid administration, it is important to maintain normothermia and increased oxygenation as previously described.
Wound Management in Contaminated Cases There are almost as many methods of managing obvious wound contamination as there are surgeons. In some cases, it may be preferable to leave the wound open or plan for a delayed closure.
Personal practice of contaminated wounds One practice is to do a primary closure over a Blake 19 drain. After the wound is closed, fill the Blake drain with wide spectrum antibiotic, clamp it, and after 2 hours release the clamp and place the drain to suction. Leave the drain in place for 10 days, because that is when suppuration usually occurs. Finally, a recent ‘‘JAMA Surgery’’ article reported in a large prospective randomized trial44 that the use of preventive bundle in both colorectal and most likely noncolorectal surgery will reduce surgical costs by decreasing superficial SSIs and postoperative sepsis. Interestingly, no significant difference was observed in deep SSIs, organ-space SSIs, wound disruption, length of stay, 30-day readmission, or variable direct costs between the match groups.
Conclusions Despite some advances, SSI remains a major cause of injury, morbidity, financial loss, and even death. That associated with colorectal operations has been particularly difficult to prevent, and has been resistant to a number of process improvements. In this presentation, we have described those processes of care that have been proven by experimental and clinical evidence to have been effective in reducing the rate of SSI in colorectal surgery and by extension noncolonic surgery. By concentrating on these precepts, agreeing to a common colorectal bundle including them, and otherwise reducing variance, surgical teams should be able to reduce their colorectal surgery SSI rate, and by extension, noncolonic surgical wound infection rate. Josef E. Fischer, M.D.* Department of Surgery, Harvard Medical School, 29 Commonwealth Avenue, Suite 110, Boston, MA 02116, USA Ronald Weintraub, M.D. Department of Surgery, Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA
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References 1. Stulberg JJ, Delaney CP, Neuhaser DV, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479–85. 2. Hawn MT. Surgical care improvement: should performance measures have performance measures? JAMA 2010;303:2527–8. 3. Hawn MT, Vick CC, Richman J, et al. Surgical site infection prevention: time to move beyond the surgical care improvement program. Ann Surg 2011;254:494–9; discussion, 499–501. 4. Madoff RD, Melton GB. Anterior and low anterior resection of rectum. In: Fischer JE, editor. Mastery of Surgery. 6th ed., Vol. 2. Philadelphia, PA: Lippincott Williams &Wilkins; 2012 Chapter 164, p 1739. 5. Stone PW, Kunches L, Hirschhorn L. Cost of hospitaldassociated infections in Massachusetts. Am J Infect Control 2009;37:210–4. 6. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011;32:101–14. 7. Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA 2010;303:2479–85. 8. 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;35:605–27. 9. Holter AR, Fischer JE. The effects of perioperative hyperalimentation on complications in patients with carcinoma and weight loss. J Surg Res 1977;23:31–4. 10. Campos AC, Mequid MM. A critical appraisal of the usefulness of perioperative nutritional support. Am J Clin Nutr 1992;55:117–30. 11. Buzby GP. Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutritional Cooperative Study Group. N Engl J Med 1991;325:525–32. 12. Lipke VL, Hyott AS. Reducing surgical site infections by bundling multiple risk reduction strategies and active surveillance. AORN J 2010;92:288–96. 13. Nelson RI, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2009:CD001181. 14. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281–6. 15. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195–283. 16. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol 2011;117:877–82. 17. Englesbe MJ, Brooks L, Kubus J, et al. A statewide assessment of surgical site infection following colectomy: the role of oral antibiotics. Ann Surg 2010;252:514–9. 18. Poth EJ. Historical development of intestinal antisepsis. World J Surg 1982;6:153–9. 19. Robson MC, Krizek TJ, Heggers JP. Biology of surgical infection. Curr Probl Surg; 1973:1–62. 20. Lewis RT. Oral versus systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta-analysis send a message from the 1990s. Can J Surg 2002;45:173–80. 21. Fry DE. Colon preparation and surgical site infection. Am J Surg 2011;202:225–32. 22. Bellows CF, Mills KT, Kelly TN, et al. Combination of oral nonabsorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials. Tech Coloproctol 2011;15:385–95.
The American Journal of Surgery, Vol 209, No 6, June 2015 23. Krapohl GL, Phillips LR, Campell Jr DA, et al. Bowel preparation for colectomy and risk of Clostridium difficile infection. Dis Colon Rectum 2011;54:810–7. 24. Hunt TK, Hopf HW. High inspired oxygen fraction and surgical site infection. JAMA 2009;302:1588–9. 25. Belda FJ, Aguiler L, Garcia de la Asuncion J, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 2005;294:2035–42. 26. Greif R, Akca O, Horn EP, et al. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med 2000; 342:161–7. 27. Hopf HW, Hunt TK, West JM, et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg 1997; 132:997–1004. 28. Meyerhoff CS, Wettersley J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery. JAMA 2009;302:1543–50. 29. Quadan M, Akca O, Mahid SS, et al. Perioperative supplemental oxygen therapy and surgical site infection; a meta-analysis of randomized controlled trials. Arch Surg 2009;144:359–66. 30. Wong PF, Kumar S, Bohra A, et al. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007;94:421–6. 31. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Treatment and Temperature Group. N Engl J Med 1996;334:1209–15. 32. Parienti JJ, Thibon P, Heller R, et al. Hand-rubbing with aqueous alcoholic solution versus traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. JAMA 2002;288:722–7. 33. Nthumba PM, Stepita-Poenaru E, Poenaru D, et al. Cluster-randomized, cross over trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 2010;97:1621–8. 34. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev 2009:CD004288. 35. Alexander JW, Fischer JE, Boyajian M, et al. The influence of hairremoval methods on wound infections. Arch Surg 1983;118:347–52. 36. Darouche RO, Wall Jr MJ, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical site antisepsis. N Engl J Med 2010;362:18–26. 37. Charoenkwan K, Chotirosniramit N, Rerkasem K. Scalpel versus electrosurgery for abdominal incision. Cochrane Database Syst Rev 2012; 6:CD005987. 38. Molgat YM, Pollack SV, Hurwitz JJ, et al. Comparative study of wound healing in porcine skin with CO2 laser and other surgical modalities: preliminary findings. Int J Dermatol 1995;34:42–7. 39. Edwards JP, Ho AL, Tee MC, et al. Wound protectors reduce surgical site infections: a meta-analysis of randomized controlled trials. Ann Surg 2012;256:53–9. 40. Misteli H, Weber WP, Reck S, et al. Surgical glove perforation and the risk of surgical site infection. Arch Surg 2009;144:553–8. 41. Kojima Y, Ohashi M. Unnoticed glove perforation during thoracoscopic and open thoracic surgery. Ann Thorac Surg 2005;80:1078–80. 42. Cina R, Dankbar E, Lovely J, et al. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience. J Am Coll Surg 2013;216:23–33. 43. Lewis GH, Vaithianathan R, Hockey PM, et al. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Q 2011;89:4–38. 44. Keenan JE, Speicher PJ, Thacker JK, et al. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 2014;149:1045–52.
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