It was reported in 2014 that approximately 14 million operations were performed in the United States.¹ The health care–associated infection prevalence survey conducted by the Centers for Disease Control and Prevention found an estimated 110,800 surgical site infections (SSIs) associated with inpatient surgical procedures in 2015.² Even though many advances have been made in infection control practices, SSIs contribute to an overall surgical mortality rate of 3%, and 75% of deaths are specific to the SSI.³

The various risk factors for SSIs include older age, obesity, smoking, a weakened immune system, the presence of chronic medical conditions, malnutrition, operations that last longer than two hours, among others. Surgical risk factors also include inadequacies with surgical scrub or antiseptic preparation of the skin. The SSI risk is increased when the patient has any of the following: trauma, shock, blood transfusion, hypothermia, hypoxia, and hyperglycemia.⁴ It is important to take as many preventive measures as possible preoperatively, but prevention of complications should continue after surgery. Postoperative preventive practices often include the use of advanced technologies, such as negative pressure wound therapy (NPWT), antimicrobial dressings, cellular and/or tissue-based products, and others.

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Risk Factors for Surgical Site Infections

Obesity is a major public health problem, and the numbers of obese individuals globally are increasing. In the United States, 9.2% of adults are morbidly obese (body mass index >40).⁵ Clinical data show that obese and morbidly obese patients had significantly greater SSI rates in clean and clean-contaminated cases but not in contaminated or dirty-infected cases.⁶

Diabetes prevalence is increasing in the United States. Consistent and comprehensive management in patients with diabetes is imperative in preventing hospital-acquired infections.⁷ Patients with diabetes who are insulin and non-insulin dependent or are taking antidiabetic agents require close management before and after surgery because of their high risk of SSIs. Clinical data show that diabetes is a major contributor to the development of SSIs.⁷

SSIs in older adults account for 11% of nosocomial infections. The risk for SSI after the age of 65 years does not increase; however, the mortality rate, length of hospital stays, and costs are greater. Prevention of SSIs in older adults is especially important in reducing the occurrence of these infections.⁸

Using Advanced Therapies to Prevent Surgical Site Infections

Patients with a history of SSIs and risk factors should begin using advanced wound therapies right away to ensure the most benefit in prevention of SSIs. Advanced technologies and therapies help smooth the road to healing and management, thereby reducing overall costs and enhancing quality of life for the patient. The combination of prevention strategies, education, and advanced technologies or therapies leads to fewer complications and greater success in achieving healing.⁹

Negative Pressure Wound Therapy
NPWT is an effective treatment for various types of wounds, including surgical site incisions. The subatmospheric pressure that is applied in NPWT creates a closed environment, preventing infection. It also helps in reducing edema and pulling the wound edges closer together.¹⁰

Antimicrobial Dressings
Antimicrobial dressings are used to help prevent infection, provide bacterial balance, and maintain a moist wound environment in both partial- and full-thickness wounds. Antimicrobial and antibacterial dressings release low concentrations of active agents to the wound to help with bacteria management while avoiding toxicity to the host cells. This dressing category may include silver, iodine, copper, polyhexamethylene biguanide (PHMB), dialkylcarbomoyl chloride (DACC), methylene blue or gentian violet, and medical-grade honey. Many antimicrobial dressings have surgical versions meant to aid in preventing infection in postoperative wounds by reducing the bacterial load in the wound.

Cellular and/or Tissue-Based Products
Cellular and/or tissue-based products involve various therapies based on cells, including stem cells, scaffolds with carrier systems, skin substitutes, autologous blood derivatives, epidermal substitutes, dermal substitutes, dermoepidermal substitutes, melanocytes, vessels, and genetic manipulation. These products and therapies encourage rapid closure by providing the wound with elements to help tissue growth and cellular advancement. They may or may not contain antimicrobial agents.

Conclusion

It is essential to begin creating a plan to prevent SSIs before the surgical procedure. The benefits of beginning advanced therapies early are to prevent, treat, and manage SSIs and to optimize overall outcomes. Utilizing advanced therapies that have a higher cost in the beginning on patients with a high risk of SSIs can help to reduce costs incurred in the event of a complication. Appropriate advanced therapies support better outcomes throughout the surgical site healing continuum. This approach reduces complications and costs, lessens hospital stays, and decreases the patient’s suffering.

For particularly at-risk patients, it may be best to begin use of advanced therapies earlier in treatment to achieve best overall outcomes. In addition, involve patients in their own care to bolster adherence. This involves educating patients early on how to take appropriate precautions (proper hand hygiene, good wound care) and manage their modifiable risk factors. Given that SSIs are the most common and costly hospital acquired infections, it is paramount that prevention and treatment are managed appropriately.

References
1. McDermott KW, Freeman WJ, Exilhauser A. Overview of operating room procedures during inpatient stays in U.S. hospitals, 2014. Healthcare Cost and Utilization Project statistical brief #233. Agency for Healthcare Research and Quality; 2017. Accessed September 27, 2021. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb233-Operating-Room-Pr…
2. National Healthcare Safety Network. Surgical site infection event (SSI). Centers for Disease Control and Prevention; 2021:9-1. Accessed September 27, 2021. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
3. Awad SS. Adherence to surgical care improvement project measures and postoperative surgical site infections. Surg Infect (Larchmt). 2012;13(4):234-237.
4. Cheadle WG. Risk factors for surgical site infection. Surg Infect (Larchmt). 2006;7(Suppl 1):S7-S11. doi:10.1089/sur.2006.7.s1-7; PMID: 16834549
5. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2019-2018. National Center for Health Statistics data brief #360. Centers for Disease Control and Prevention; 2020. Accessed September 27, 2021. https://www.cdc.gov/nchs/products/databriefs/db360.htm
6. Winfield RD, Reese S, Bochicchio K, Mazuski JE, Bochicchio GV. Obesity and the risk for surgical site infection in abdominal surgery. Am Surg. 2016;82(4):331-336. PMID: 27097626
7. Martin ET, Kaye K, Knott C, et al. Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2016;37(1):88-99. doi:10.1017/ice.2015.249
8. Kaye KS, Schmader KE, Sawyer R. Surgical site infection in the elderly population. Clin Infect Dis. 2004;39(12):1835-1841. doi:10.1086/425744; PMID: 15578408
9. Armstrong DG, Bauer K, Bohn G, et al. Principles of best diagnostic practice in tissue repair and wound healing; an expert consensus. Diagnostics (Basel). 2020;11(1):50. Accessed September 3, 2021. https://doi.org/10.3390/diagnostics11010050
10. Meloni M, Izzo V, Vainieri E, Giurato L, Ruotolo V, Uccioli L. Management of negative pressure wound therapy in the treatment of diabetic foot ulcers. World J Orthop. 2015;6(4):387-393. doi:10.5312/wjo.v6.i4.387

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.