Preventing Wound Infection in Orthopaedic Surgery

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Introduction

Wound infection post-surgery, now preferably known as Surgical Site Infection (SSI) refers to infections at or near a surgical site within 30 days after surgery or within one year, if the procedure involved insertion of an implant (Illingworth et al., 2013; Owens and Stoessel 2008). While definite statistics of the incidence of SSI are complicated given the gamut of surgical procedures, environment and patients, available data indicate that SSI contributes to more than 15% of reported Hospital-acquired infections (HAI) for all patients and about 38% for surgical patients (Campbell et al., 2013; Owens and Stoessel, 2008; Reichman and Greenberg, 2009). Also, data from across Europe indicate that, depending on surgical procedure and/or surveillance methods used, incidence of SSI may be as high as 20% for all surgical procedures (Leaper et al., 2004). Although, HAIs generally, and SSI are relatively less common in Orthopaedic surgery, compared with other surgical procedures (Johnson et al., 2013), however, when they do occur, osteo-articular infections for example, can be very difficult to treat, with significant risk of lifelong recurrence (Faruqui and Choubey, 2014). SSI leads to significantly higher costs of care from longer hospital stays; it poses a major burden on healthcare providers and the healthcare system, jeopardises the health outcomes of patients and remains a major cause of morbidity and mortality despite improvements in surgical procedures and infection control techniques (Owens and Stoessel, 2008; Tao et al., 2015). Consequently, understanding evidenced-based approaches to reduce/prevent incidence of SSI has attracted significant interests from researchers, healthcare administrators and policy-makers. This essay intends to review current best-practices in prevention of SSIs and to offer recommendations for future practice within orthopaedic settings.

Rationale

This review of best practices in the prevention of SSI following orthopaedic surgery is underpinned by two major reasons. One, despite the considerable improvement in surgical procedures and techniques in most orthopaedic settings, SSI negatively impact on patient outcomes and imposes significant cost on the healthcare system. According to a case-control study reported by Owens and Stoessel (2008), patients who suffer SSI are more likely to require readmission to hospital and have more than double the risk of death compared to patients without SSI. In addition, the median duration of hospitalisation required due to SSI was put at 11 days and the extra cost to the healthcare system estimated at ˆ325 per day (Owens and Stoessel, 2008). Two, the prevention of SSI is hardly straightforward. Given the wide range of factors that modify the risk of SSI, a ‘bundle’ approach with ‘systematic attention to multiple risk factor’ is required for any effective prevention of SSI (Uckay et al., 2013). Thus, by undertaking a state-of-the-art review of orthopaedic SSI prevention techniques/processes, this essay may contribute towards better orthopaedic surgery outcomes for patients and providers.

Prevention of SSI in orthopaedic surgery: Best Practices

According to the Health Protection Agency (2011), the most common pathogenic organisms responsible for surgical wound infections in orthopaedic surgery include methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), Coagulate negative Staphylococci (CoNS), Enterobacteriaceae, Enterococcus spp, Pseudomonas spp, Stretococcus spp as well as occasional cases of unspecified diphtheroids’ of the Corynebacterium spp. and other gram-positive organisms. Moreover, SSIs can be categorised into superficial incisional, deep incisional and organ space SSI (Reichman and Greenberg, 2009). Superficial incisional SSI refers to infection that involves only skin and subcutaneous tissue at the point of incision; deep incisional SSI refers to infection of the underlying soft tissues, while organ space SSI refers to infection involving organs or organ spaces that were opened or manipulated during the surgical procedure. Since the risk of ending up with SSI and the specific type of SSI suffered are determined by factors related to the patient, procedure and hospital environment, current best-practices and guidelines for preventing SSI can be broadly elaborated under these categories.

Patient-related Practices

Existing patient conditions like diabetes mellitus, obesity and/or rheumatoid arthritis have been associated with increased risk of SSI (Illingworth et al., 2013; Johnson et al., 2013). As part of effective patient management, pre-operatively, current body of evidence recommends aggressive glucose control for diabetes patient to reduce the heightened risk of infection due to hyperglycaemia pre or post-surgery. In patients with rheumatoid arthritis, corticosteroids and anti-tumour necrosis factor (TNF) therapy have been argued to delay wound healing and increase risk of infection. However, the British Society for Rheumatology (BSR) recommends that in deciding whether to cease these medications for such patients, pre-surgery, the potential benefits of preventing post-surgery infection should be balanced with the risk of disease flare, pre-surgery (Dixon et al., 2006; Luqmani et al., 2006). In addition, orthopaedic surgery for patients who currently smoke or are obese (BMI above 30kg/m2) should be delayed (until smoking cessation/loss of weight) to reduce the risk of SSI. For example, a randomised, controlled study reported that smoking cessation for just 4 weeks significantly reduced the odds of incisional SSI (Sorensen et al., 2003), while Namba et al. (2005) reported significantly higher odds of SSI in obese patients (>35kg/m2) undergoing total hip and knee replacement surgery, compared with patients that were not obese.

Screening patients for presence of MSSA and MRSA and subsequent decolonisation is one of the most recommended techniques for preventing SSI. Staphylococcus aureus colonisation is reportedly found in the nares of about 30% of healthy individuals (Kalmeijer et al., 2002). This nasal carriage of both methicillin sensitive/resistant S. aureus have been demonstrated as a significant risk factor for SSI. Kelly et al. (2012) reported a significant drop in SSI from 2.3% to 0.3% with the use of intranasal mupirocin and triclosan showers to decolonise patients before orthopaedic surgery. Also, a review of eight randomised controlled trial by van Rijen et al. (2008) reported that the use of mupirocin significantly reduced the incidence of MRSA and MSSA associated SSI. However, guidelines from the National Institute for Health and Care Excellence (NICE, 2008) recommends a combination of nasal mupirocin and chlorhexidine showers for patient decolonisation while Uckay et al. (2013) indicated that available evidence from orthopaedic literature suggests that S. aureus screening, decolonisation and shower constitute a cost-saving, effective strategy to reduce the incidence of SSI in orthopaedic surgeries.

Surgical Procedure-related Practices

Preoperative preparation of skin before incision is one of the major avenues to prevent SSI (Kelly et al., 2012). However, there is no consensus on what antiseptic agent offers the most effective protection against SSI. While NICE (2008) guidelines suggest that both aqueous and alcohol based preparations e.g. povidone-iodine or chlorhexidine are suitable for skin preparation, Darouiche et al. (2010) and Milstone et al. (2008) have raised concerns about the development of bacterial resistance to chlorhexidine. These studies report the relative superiority of 2% chlorhexidine mixed with 70% isopropyl alcohol, while some experts have suggested increasing the chlorhexidine concentration to 4% or the use of 10% povidone-iodine (Uckay et al., 2013). Nevertheless, povidone-iodine or chlorhexidine still remain the gold standard for preoperative skin preparation.

Also as part of skin preparation, NICE recommends that hair should only be removed if necessary, should be done immediately before surgery and with electronic clippers, not razor blades. Recent evidence suggests that use of razor blades can sometimes result in microscopic skin cuts that may act as foci for micro-organisms colonisation, thus increasing the risk of infection (Owens and Stoessel, 2008).

Preoperative administration of antibiotic prophylaxis to reduce the risk of surgical wound infection is widely accepted for surgery in orthopaedic settings, including bone trauma. Several large scale studies have demonstrated that antibiotic prophylaxis, when administered properly, help reduce tissue contamination, during surgery, to levels that do not overwhelm the patient’s immune system, and thus, can reduce the risk of SSI by up to 75% (Chen et al., 2013; Faruqui and Choubey, 2014; Illingworth et al., 2013; Uckay et al. 2013). However, NICE (2008) recommends that potential adverse effects, optimal dosage and most effective time for administration pre-operatively should be carefully considered to maximize the benefit of antibiotic prophylaxis. Uckay et al. (2013) believe that first or second generation parenteral cephalosporins are sufficient in most cases, except in cases of skin colonisation with MRSA, in which case glycopeptide antibiotics may be more effective. However, this should be considered in relation to individual patients’ allergy history. Uckay et al. (2013) also recommend that 30mins – 1hr before incision is the idea time to administer prophylaxis. While this is generally accepted, NICE (2008) recommends that prophylaxis may be given earlier in procedures where a tourniquet is used.

In addition to minimising the risks from the skin and endogenous flora of the patient, the surgical team must also strive to reduce chances of contamination from either their person, the tools used or the procedure itself. NICE (2008) recommends that every member of the surgical team must thoroughly scrub before wearing surgical gown and gloves. There is growing support for double-gloving and frequent glove-changing to reduce the risk of contamination from tiny punctures in surgical gloves that often go unnoticed during surgery. While evidence in support of double-gloving and/or frequent glove-changing intra-operatively as a strategy for reducing risk of SSI remain inconclusive, Widmer et al. (2010) conclude that the practice is supported by expert opinion, especially for lengthy procedures. Moreover, excellent surgical techniques are crucial in preventing SSI. For example, maintaining effective haemostasis while preserving adequate blood supply, removal of devitalized tissues, eradication of dead space(s), gentle handling of tissue and effective management of surgical wound postoperatively can all help reduce the chance of SSI (Uckay et al., 2013).

Hospital Environment-related Practices

The CDC and World Health Organization recommend that doors to the operating room should be kept closed and traffic kept to a minimum to reduce potential contamination of surgical sites (Tao et al., 2015). To achieve this, essential equipment and tools should be stored in the operating room. In fact, Health Protection Agency (2011) suggest that frequency of operating room door opening is a positive predictor of increased bacterial count in the operating room. Airflow in the operating room is another modifier of SSI risk. Vertical or horizontal laminar-flow ventilation systems have been advocated for orthopaedic surgery to achieve ultra-clean air within the operating room and reduce airborne contaminants. Although evidence supporting the effect of laminar airflow systems on SSI risk remains inconclusive, the reduction in airborne contaminants is perhaps an added advantage (Owens and Stoessel, 2008; Reichman and Greenberg, 2009).

Lastly, constant surveillance is an important part of preventing SSI. By following up on patients post-operatively and reporting appropriate data to the surgical team, surgical decisions can be improved upon based on historical records (Skramm et al., 2012). Moreover, surveillance ensures that cases of SSI are identified early and treated before complications arise. Data from surveillance could also form the basis of evidenced-based decision making on facility specific service improvements to reduce incidences of SSI and improve outcomes for all concerned (Skramm et al., 2012).

Recommendations

This essay have reviewed current knowledge on surgical site infection and strategies to reduce its incidence. It is pertinent to state that despite the various precautions elaborated above, complete eradication of surgical site contamination is almost impossible as some endogenous micro-organisms always remain and environmental factors cannot be totally eliminated. To reduce incidence of SSI to the barest minimum, the following are recommended:

It is crucial to adopt a ‘bundle’ approach that ensures that patient, procedure and facility related factors are controlled for as much as possible.
While improving surgical and care delivery is always crucial, surveillance and data collection should also promoted to ensure that changes/improvements in procedures and facility practices are evidenced-based
New technologies and strategies are continually been developed to reduce complications like SSI and improve outcomes for patients, it is important to always stay on top of these developments to ensure that orthopaedic surgeries are not only evidenced-based but contemporary, achieving the best outcome possible for all parties.
Conclusion

Surgical site infection (SSI) poses a significant challenge to patients undergoing orthopaedic surgeries, the surgical team as well as the healthcare system in general. SSI negatively impact patient outcomes and imposes unnecessary demand on healthcare resources. Fortunately, much of the burden associated with SSI can be avoided. This review identifies the multitude of patient and procedure-related factors that modify SSI risk and highlights various evidence-based strategies to mitigate these risks. The paper demonstrates that there is consensus in the literature that by screening and subsequent decolonisation of patients, administering antibiotic prophylaxis, ensuring that surgical tools, equipments and garments are properly sterilised and the operating room is free of airborne contaminants, cases of surgical wound infection in orthopaedic surgeries can be effectively prevented.

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