Surgical site infections (SSIs) can occur within 30 days after surgery. SSIs are associated with increased morbidity, prolonged hospital stay or readmission, and increased health-care costs. SSIs occur in approximately 2% to 5% of all patients undergoing gynaecological surgery. By implementing best practices, 40% to 60% of SSIs are preventable.
Gillispie-Bill (2020) reviews risk factors, and best practices for preventing SSIs associated with gynecologic surgery. Here we summarise the findings:
Risk factors
Risk factors for SSIs can be divided into 2 groups: patient risk factors and operative risk factors.
Patient risk factors
- Smoking. The American College of Surgeons report active smokers have a 40% higher risk of postoperative surgical complications, and this includes SSI. Vasoconstriction leads to tissue hypoxia. Smoking also harms the immune system.
- Obesity. This is due to the increased ratio of adipose tissue to capillary density, which leads to poor tissue perfusion. This risk is particularly high for patients undergoing abdominal surgeries such as hysterectomy.
- Diabetes
- Malnutrition
- Age
Operative risks
These include:
- Longer surgery duration. This is potentially due to temperature regulation, inflammation, and anaesthesia management.
- Intraoperative blood transfusion, especially for organ space infections.
- Wound classification is another operative risk factor. The CDC categorises operative procedures and their wounds as clean, clean-contaminated, contaminated, or dirty/infected. Hysterectomy is a clean-contaminated procedure. Overall, clean-contaminated procedures have an average infection rate of 3.94%; the aim of best practices is to lower this rate.
Best practices to reduce surgical site infection
These are grouped into preoperative, intraoperative, and postoperative activities:
Preoperative
- Patient showering: With soap or an antiseptic agent at least the night before surgery. A 2015 Cochrane review demonstrated no benefit to showering with bar soap vs chlorhexidine. However, there was a statistically significant reduction in SSIs after a full wash with chlorhexidine vs a partial wash. Either plain soap or an antimicrobial soap may be equally effective, but in a full body wash.
- Hair removal: Hair should not be removed unless it will interfere with the procedure. If hair needs to be removed, clippers instead of a razor should be used because razors can cause microtrauma to the skin. Hair should be removed in the preoperative area (not the operating room).
- Glycemic control: The stress of surgery causes dysregulation in glucose production and glucose utilisation. From 12% to 30% of patients undergoing surgery are found to have hyperglycemia, even in the absence of a history of diabetes. Perform a fasting blood sugar test on all patients prior to surgery, regardless of diabetes history.
- Surgeon hand and forearm scrub: The traditional 10-minute hand and forearm scrub is no longer recommended. Scrubbing for 2 to 6 minutes is as effective for reducing bacteria. Either an antimicrobial soap or an alcohol-based scrub should be used with or without a sponge but not with a brush. Alcohol-based scrubs with chlorhexidine provide the best immediate and persistent antimicrobial activity. A prewash with a nonantimicrobial soap and drying before applying the alcohol-based scrub is recommended. Even with appropriate washing, all skin flora and bacteria may not be removed. An important consideration during lengthy procedures is double-gloving.
Recommendations for surgeons to provide to patients before surgery
- Advise stop smoking for at least 4 to 6 weeks prior to surgery.
- Weight-loss interventions for obese patients
- Written instructions on hair removal and showering.
Intraoperative considerations
- Antibiotic prophylaxis: Preoperative antibiotic prophylaxis is the current standard of care for hysterectomies.
- Skin preparation in the operating room: Several skin preparations are available, and they vary in onset of action, duration, and antimicrobial coverage. A solution of alcohol with chlorhexidine gluconate is ideal.
- Operating room environment: Perioperative hypothermia can increase the risk of SSI.
Postoperative
- Surgical site dressing: A 2016 Cochrane review determined that no one dressing was superior for prevention of SSI, so consensus is lacking on what type of dressing is best for prevention of SSI. The CDC recommends the dressing is kept on for 24 to 48 hours after surgery.
- Vacuum assisted wound closure: Prophylactic vacuum-assisted wound closure has been shown to reduce the risk of SSI in patients who undergo cesarean section/abdominal surgery.
- Patient instructions: Patient instructions should address wound care after surgery, and be suitable to the health literacy of the patient.
Using several evidence-based strategies (bundle) is more likely to have an impact rather than pursuing any single strategy on its own.
Source: Gillispie-Bell, V. Prevention of Surgical Site Infections in Gynecologic Surgery: A Review of Risk Factors and Recommendations. Oschner J, 2020;20:4.