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WOUND MANAGEMENT

Prevention of surgical site neutrophils and continuation of normal wound healing or the
development of a wound infection. The classical symptoms of

infections inflammation (calor, rubor, tumour and dolour) develop due to


the increased blood supply, accumulation of tissue fluid and
exudates and stimulation of pain receptors. Whether an SSI de-
Jessica Phillips
velops depends upon the number of bacteria present, the ability
Helen O’Grady of the bacteria to produce infection (virulence), the wound
Elizabeth Baker environment and the ability of the patient to fight infection.4 SSI
effects may remain localized to the operative site or produce
systemic effects due to the systemic inflammatory response
Abstract syndrome (SIRS). The resulting SSI either will be one that can be
Surgical site infections (SSI) are commonly classified as superficial, deep managed easily as an outpatient, or one that leads to an extended
or organ/space infections in wounds that may be clean, clean- inpatient stay, reoperation and associated morbidity and
contaminated or dirty. The development of an SSI depends on patient, mortality.
procedure and pathogen factors. Their incidence varies depending on
procedure and they have a significant impact upon patient morbidity
Risk factors (Table 2)
and healthcare resources. National guidelines compromise of a care
bundle, aimed at reducing their incidence with preoperative, intraopera- As mentioned previously, various factors influence the devel-
tive and postoperative factors. This includes optimizing patient co- opment of an SSI. Some of these will be modifiable, some not.
morbidities, appropriate antibiotic use, skin preparation, theatre disci- The nature of the causative organism is related to the site and
pline, theatre ventilation, and surgical technique. Wound care may be type of surgery. Table 3 lists the common types.
simple for those healing by primary intention or require specialist tech-
niques if healing by secondary intention.
Diagnosis and investigations
Keywords Hospital-acquired infection; prevention; surgical site infec-
tion; wound sepsis Clinical findings consistent with SSI include localized symptoms
of tenderness, erythema, heat, fluctuance, discharge and sys-
temic symptoms of pyrexia, rising inflammatory markers. Deep
Definition space infections may result in failure to progress and ileus. It is
important to take blood cultures and swabs prior to the instiga-
Wounds can be defined as being clean, clean-contaminated, tion of antibiotics. These should be chosen in line with local
contaminated or dirty (Table 1). This depends on the presence protocols and tailored towards the likely organisms involved
of inflammation or necrosis, the anatomical tract operated upon, with further review once microbiology results are available.
spillage of gastrointestinal contents and whether the wound is Wounds are most commonly classified by the CDC definitions.1
old, traumatic or new. Surgical site infections (SSI) are infections
within a wound occurring up to 30 or 90 days (if a prosthesis is
involved) postoperatively. These may be superficial, involving Prevention
only skin and subcutaneous tissue, deep if muscle and fascia are The National Institute for Health and Care Excellence (NICE)
involved, or an organ/space infection when other spaces that are takes the view that the majority of SSI are preventable, and is-
open or manipulated during the procedure become infected.1 sued national UK guidance in 2008 (Table 4).7 This guidance
The incidence of SSI is variable depending on the surgical outlines measures to be taken at each step of the operative
procedures involved and the definitions used. In a survey of 140 journey to minimize SSI. The application of a group of recom-
hospitals in 4 years across the UK, the infection rate was 4% mendations based upon literature evidence to improve patient
overall, but 14% in limb amputations.3 SSI results in a significant outcomes is known as a ‘care bundle’.
increase in the length of hospital stay, cost, use of outpatient
resources, morbidity and mortality.3
Preoperative measures
Optimizing risk factors
Pathology and pathogenesis
Modifiable risk factors should be addressed prior to elective
Contamination of a wound stimulates an inflammatory response surgery such as weight reduction, smoking cessation, alcohol
in the patient and either successful clearance of infection by abuse, diabetic control.8 Some factors cannot be modified such
as patient age, and some are not possible in an emergency.
Emergency surgery is in its self a risk factor for SSI.8
Jessica Phillips FRCS(Eng) MSc is an ST7 in Surgery at Castle Hill Hospital,
Hull, UK. Conflicts of interest: none declared. Hair removal
Clipping hair rather than shaving results in less SSI, but no dif-
Helen O’Grady FRCS is a Consultant Colorectal Surgeon at Castle Hill
ference if this is done on the day or the day before surgery.9
Hospital, Hull, UK. Conflicts of interest: none declared.
There is no evidence to suggest that the presence of hair in-
Elizabeth Baker MBChB MRCS(Ed) is a Specialist Trainee in General Surgery creases SSI. It is thought that the small wounds resulting from
at Castle Hill Hospital, Hull, UK. Conflicts of interest: none declared. shaving may harbour bacteria.

SURGERY 32:9 468 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT

Wound types and infective rates2


Class Type Definition Example Infection Infection rate % before
rate % antibiotic prophylaxis

I Clean No entry into viscus or tract Joint replacement, breast, hernia 1e2 1e2
II Clean- Hollow viscus opened but with minimal Cholecystectomy, elective colorectal <10 30
contaminated contaminated spillage resection, uncomplicated appendicectomy
III Contaminated Viscus or tract opened with significant Accidental enterotomy 15e20 <60
spillage or inflammatory process
IV Dirty Gross contamination secondary to pus or Perforated diverticular disease <40 60
perforation, incision through an abscess

Table 1

Prophylactic antibiotics Intraoperative measures


Prophylactic antibiotics are a single dose of antibiotic given at or
Theatre protocol
prior to the induction of anaesthesia. This is recommended for
Sources of infection within theatre can be from the patient, staff
any surgery apart from clean procedures not involving an
or the theatre environment itself. While it is traditionally thought
implant or prosthesis.7 Antibiotics come with the risk of associ-
that specific theatre clothing reduces infection, evidence is
ated infections such as Clostridium difficile, resistant organisms,
limited.12 However, NICE guidance feels that by continuing this
adverse reactions and cost. The choice of agent should take into
theatre discipline will be better maintained and hence may
account the likely organisms present in the procedure that could
reduce SSI.7 Nails should also be kept short, free from polish and
lead to SSIs, local guidance, and patient factors (allergies,
those with active skin conditions should avoid theatre.
immunosuppression). The agent should be given earlier if a
tourniquet is used, and repeated if the procedure is prolonged Surgical scrubbing
longer than the half-life of the antibiotic. The evidence for the Cleaning hands reduces SSIs, aided by the use of antimicrobial
reduction in SSI by using prophylactic antibiotics is well washes and double-gloving which also minimizes transmission
established.10 of infection from the patient to the operator. NICE guidelines7
recommend aqueous antimicrobial wash for the initial case,
MRSA eradication
and alcohol rub or antiseptic solutions for subsequent cases if
Many institutions screen for MRSA at preoperative assessment or
visibly clean. Systematic reviews suggest that alcohol rubs are as
emergency admission. MRSA is known to increase the risk of SSI,
effective as aqueous in reducing bacterial load on the hands, but
and if this is screened and eradicated this risk can be reduced.11
there is a lack of evidence for the use of nail files and brushes.13
MRSA is treated with mupirocin 2% ointment intranasally and
2% chlorhexidine skin wash for 5 days. Skin preparation and draping
The skin of the surgical field is prepared by the application of an
antiseptic solution. A multicentre RCT found a significant
Risk factors for surgical site infections2,5,6 improvement in both superficial and deep SSI when skin was
Non-modifiable Modifiable prepped using 2% chlorhexidine gluconate and 70% isopropyl
alcohol rather than 10% povidoneeiodine.14 It is important to
Infective load Infective organism remember to allow flammable alcohol-based skin preparations to
Virulence Infective organism evaporate, and avoid pooling and soaking of drapes prior to the
Wound Mechanism of wound Procedure sterility use of diathermy. Chlorhexidine and alcohol-based solutions are
environment Anatomical site operated Technique irritants and drying to mucous membranes, so anatomy of the
upon (wound type) Use/type of prosthesis surgical field must also be considered.
Duration of procedure Draping allows the physical exclusion of the sterile operative
Wound haematoma field from the rest of the patient and non-sterile members of the
Patient factors ASA 3þ Hyperglycaemia theatre team. A review of evidence found no difference between
Age Hypothermia SSI rates between reusable or disposable drapes.7 Disposable
Immunosuppression Hypoxia drapes and gowns are preferable when blood-borne infections
Malnutrition Anaemia are present.
Obesity Blood transfusion
Diabetes Smoker Gloving and gowning
Ascites As with drapes, no advantage for reducing SSI rates has been
Renal failure found with either disposable or reusable gowns,7 or with the
Jaundice practice of double-gloving. However, glove perforation is known
to increase the risk of SSI.15 Double-gloving is preferential if there
Table 2 is a high risk of blood-borne infection transmission to the

SURGERY 32:9 469 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT

Surgical site and likely infective wound pathogens6


Surgical site Staphylococcus Coagulase-negative Gram-negative Streptococci Anaerobes Others
aureus staphylococci bacilli

Cardiac
Neurosurgery
Breast
Ophthalmic
Orthopaedic
Vascular
Gastroduodenal Oropharyngeal anaerobes
Biliary
Colorectal
Head and neck Oropharyngeal anaerobes
Obstetric and Enterococci, group B streptococci
gynaecological
Urological
Foreign material

Table 3

surgeon or if transmission to the patient would be especially 300 air changes per hour are generated and bacterial load is
hazardous, for example with joint replacements. reduced.16

Ventilation systems within the theatre suite Good surgical technique


A positive pressure gradient and air filters between the theatre Minimizing devitalized tissue by using an adequate incision
environment and its surroundings aims to reduce airborne length, limiting the undermining of surrounding tissues and
pathogens and contamination. Conventional (turbulent) venti- using diathermy judiciously can help reduce SSI.17 There is no
lation changes the air 20 times per hour. Temperature and hu- evidence to suggest that diathermy for the incision will impact on
midity are maintained between 18e25 C and 40e60%.16 SSI rates, although NICE guidance recommends it is not used.7,18
Laminar ventilation in orthopaedic suites consistently circulates Sutures can increase the risk of SSI by increasing the amount of
highly filtered positive pressure air onto the operative field. Up to foreign material present or if a braided suture is used,17 however

NICE guidance on preventing surgical site infections7


Preoperative Shower/bathe either the day before surgery or the day of the surgery
Remove hair with electrical clippers if required. Do not use razors to remove hair
Patients and staff to wear specific theatre clothing, and remove nail polish and jewellery
Avoid routine MRSA nasal decontamination and bowel preparation
Use antibiotic prophylaxis for all but clean surgery with no prosthesis or implant, using local policies
Do not use mechanical bowel preparation routinely
Intraoperative Decontaminate hands
Use indophor-impregnated incise drapes if required
Wear sterile gowns and double glove if high risk of contamination
Prepare skin with antiseptic chlorhexidine/povidoneeiodine preparation
Avoid diathermy for skin incisions
Maintain normothermia, perfusion, and aim for Hb saturation of 95%
Cover wounds with dressings
Do not use wound irrigation or intracavity lavage to reduce the risk of surgical site infection
Postoperative Change dressings aseptically
Clean wounds with sterile saline up to 48 hours, tap water after this
Involve tissue viability specialists for wound dressings on wounds healing by secondary intention
Use appropriate antibiotics for infected wounds

Table 4

SURGERY 32:9 470 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.
WOUND MANAGEMENT

there is insufficient evidence to make definite recommendations 3 Coello R, Charlett A, Wilson J, Ward V, Pearson A, Borriello P. Adverse
on technique or the type of suture.7 New studies are investigating impact of surgical site infections in English hospitals. J Hosp Infect
the use of antimicrobial impregnated suture materials. Haemo- 2005; 60: 93e103.
stasis is important to limit haematoma formation which can act 4 Pathogenesis of SSI. http://www.medscape.org/viewarticle/448981_2
as a nidus for subsequent infection; this can be achieved by local (accessed 21 Feb 2014).
techniques and by maintaining adequate oxygenation, perfusion, 5 Culver D, Horan T, Gaynes R, et al. Surgical wound infection rates by
temperature and glucose control.7 The use of drains is not rec- wound class, operative procedure, and patient risk factors. Am J Med
ommended routinely7,19 and if needed should preferentially be a 1991; 91: S152e7.
low vacuum system exiting at a distance to the wound. There is 6 Mangram A, Horan T, Pearson M, et al. Guideline for the prevention of
no evidence to support the use of topical antiseptics or antimi- surgical site infection, 1999. Hospital Infection Control Advisory
crobials prior to wound closure.7 Committee. Infect Control Hosp Epidemiol 1999; 20: 250e80.
7 Surgical site infection: prevention and treatment of surgical site
Postoperative measures infection NICE. 2008, http://www.nice.org.uk/nicemedia/live/11743/
42378/42378.pdf.
Wound care
8 Neumayer L, Hosokawa P, Itani K, El-Tamer M, Henderson W, Khuri S.
Wounds are covered with a sterile dressing. Dressings are
Multivariable predictors of postoperative surgical site infection after
initially changed using an aseptic technique.7 Patients are
general and vascular surgery: results from the patient safety in sur-
encouraged to allow the wound to dry up before immersing it
gery study. J Am Coll Surg 2007; 204: 1178e87.
when bathing.
9 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to
reduce surgical site infection. Cochrane Database Syst Rev 2006; 19.
Complex wound care
CD004122.
Complex wounds should be managed in conjunction with a tis-
10 Andersen B, Kallehave F, Andersen H. Antibiotics versus placebo for
sue viability team7 who can advise and assist with dressing types
and management. Wound healing is affected by both local and prevention of postoperative infection after appendicectomy.
systemic factors, as discussed and listed in Table 2. Contami- Cochrane Database Syst Rev 2005; 3. CD001439.
nated wounds are left to heal by secondary intention and may be 11 Bode L, Kluytmans J, Wertheim H, et al. Preventing surgical-site in-
packed with interactive dressings such as alginate, or gauze. fections in nasal carriers of Staphylococcus aureus. N Engl J Med
They require monitoring and planned dressing changes. Wounds 2010; 362: 9e17.
may dehisce and heal by secondary intention. Necrotic tissue 12 Sivanandan I, Bowker K, Bannister G, Soar J. Reducing the risk of
surgical site infection: a case controlled study of contamination of
should be debrided.7 This can be autolytic, shedding aided by
theatre clothing. J Perioper Pract 2011; 2: 69e72.
dressings, using biological agents (larvae) or surgical debride-
13 Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce
ment using a scalpel. Topical Negative Pressure (TNP) therapy
surgical site infection. Cochrane Database Syst Rev 2008; 1.
(or Vacuum Assisted Closure e VAC) can be used to aid the
CD004288.
closure of large wounds. A foam dressing is inserted into the
wound cavity, covered by an occlusive dressing and attached to a 14 Darouiche R, Wall M, Itani K, et al. Chlorhexidine-alcohol versus
vacuum pump. This removes exudates and promotes povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362:
granulation.20 18e26.
15 Misteli H, Weber W, Reck S, et al. Surgical glove perforation and the
Conclusion risk of surgical site infection. Arch Surg 2009; 144: 553e8.
16 Damani N, Emmerson A. Manual of infection control procedures. 2nd
Surgical site infections are an important and significant health- edn. Greenwich Medical Media, 2003.
care problem causing morbidity and a strain on resources. 17 Alexander J, Solomkin J, Edwards M. Updated recommendations for
Standards of care at each point of the operative journey should control of surgical site infections. Ann Surg 2011; 253: 1082e93.
be maintained to reduce the risk of an infection occurring. A 18 Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of
cutting diathermy versus scalpel for skin incision. Br J Surg 2012; 99:
613e20.
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SURGERY 32:9 471 Crown Copyright Ó 2014 Published by Elsevier Ltd. All rights reserved.

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